Sleep aids and medicines: the options, in order

Before anyone reaches for a pill: what helps, what to skip, and what to ask the doctor. The rest of the night plan is on Sleep: for both of you.

Why sleep matters: the brain repairs itself at night

• Deep sleep is when the brain cleans house. (Fluid flushes waste, including amyloid, out of the brain faster during sleep.)
• One bad night shows up. (After a single night without sleep, 20 healthy adults had more amyloid in memory areas of the brain.)
• Years of short sleep add risk. (Six hours or less a night in your 50s and 60s was linked to about a 30% higher dementia risk over 25 years.)
• Nightly sleeping pills are a poor trade. (Over 60, they add about 25 minutes of sleep but make memory and confusion problems nearly five times as common. In mice, zolpidem (Ambien) slowed the brain's overnight cleaning.)

So: build natural sleep first, and treat apnea. On a prescribed sleep medicine? Do not stop it suddenly; ask the prescriber for a plan. Watch: how the brain cleans itself while you sleep (12 min). ReCODE works on sleep early, too.

Getting sleep: the options, in order

Start at the top and work down. (Medicines come last: even those with dementia evidence carry fall risk. Prices appear only where we checked them.)

First: free, at home

• The steps in the day builds the night, done together. (Evidence: moderate together, thin for any one step alone. Risk: a fall on the walk if they are worn out.)
• Fewer drinks late in the evening and the toilet at bedtime, but plenty to drink by day. (Expert advice, no trials. Risk: too little fluid raises delirium risk.)
• A dark, cool, quiet bedroom, with a lit path to the toilet. (Expert advice, no trials. Risk: trips in the dark. Mostly free: a calmer room.)
• Ask the doctor about a coached sleep program for you, the carer. (Evidence: moderate. In England, DREAMS START, six one-hour sessions for family carers, beat usual care in a 377-family trial. No risks reported. Free where offered; we could not confirm it outside England.)

Next: things families buy or try

• Light box: only if they cannot get outside, and tell the doctor. (A bright morning lamp. Evidence: thin and mixed. A US guideline weakly supports it; a Cochrane review found no clear effect.)
• Weighted blanket: ask the doctor first, and only if they can push it off alone. (One small dementia study, no comparison group. Risks: being trapped, heat, and trouble for the frail or short of breath. $160 to $280 for the models one 2026 review tested; it earns shop commissions.)
• White noise: skip it, unless it covers one noise, like traffic. (Very low evidence that steady noise helps sleep. It may disturb sleep and hearing.)

Skip: "PM" pills from the store

• Do not give Tylenol PM, Advil PM, ZzzQuil or Unisom. (They contain diphenhydramine or doxylamine, which the 2023 Beers Criteria, the geriatric safety list, says to avoid from age 65. They add confusion, falls and delirium.)
• Read the box for "PM", diphenhydramine or doxylamine. (Same brand, different drug: Unisom SleepTabs are doxylamine, SleepGels are diphenhydramine. Both are on the avoid list.)
• Pain keeping them up? Ask the pharmacist for the same pain reliever without the "PM".

Last: ask the doctor

What a doctor may raise, and what to ask. (Very few drug trials exist for sleep in dementia. A US guideline strongly advises against sleep medicines for older people with dementia and irregular sleep: falls and other harms outweigh the gains.)

• Trazodone: ask, "What is the fall risk?" (An older antidepressant, often used for sleep. Evidence: thin; one 2-week trial in 30 people found about 42 more minutes of sleep. In nursing homes, new users had fall injuries as often as new users of Valium-type drugs. Generic.)
• Suvorexant (Belsomra): ask about falls and next-morning drowsiness. (It blocks a wake signal. Evidence: moderate, about 28 more minutes a night, but no fewer wake-ups. In its Alzheimer's trial, 2 in 100 fell on it and none on the dummy pill. The label warns of sleepwalking-type behavior and dream-like hallucinations. Brand only.)
• Lemborexant (Dayvigo): ask what the evidence is in dementia. (Same family as Belsomra, with one small early trial in Alzheimer's. Its label warns of higher fall risk in older people. Brand only.)
• Mirtazapine: ask why, if it is offered for sleep. (A sedating antidepressant. In one small Alzheimer's trial, night sleep did not improve and daytime sleepiness rose. It can lower blood sodium.)
• Ambien-type or Valium-type sleeping pills: ask what else could be tried. (The Beers list says avoid them in older adults: more confusion, delirium, falls and fractures, for little extra sleep. No trials in dementia. A specialist may still use clonazepam for acting out dreams.)
• An antipsychotic offered "to help them sleep"? Ask, "Is this for sleep? What should we try first?" (Such as quetiapine (Seroquel), risperidone or haloperidol. They carry an FDA boxed warning: a higher risk of death in older people with dementia. Guidelines keep them for severe distress or risk of harm, not sleep.)

For any sleep medicine, ask:

• "What is causing the waking? Could it be pain, the bladder, apnea, restless legs, low mood or a medicine?"
• "Is anything on the medication list a sleep-stealer, or timed wrong?" (Donepezil, rivastigmine and galantamine can cause insomnia and strange dreams. The donepezil label says to take it in the evening, so any change is the prescriber's call. An evening water pill puts the bladder on night duty.)
• "What does this drug do for people with dementia? Is there a trial?"
• "What is the fall risk? What should I watch for the next morning?"
• "Does it add to anything else they take that causes drowsiness or confusion?"
• "How long do we try it, how will we know it is working, and how do we stop it?"