Key takeaways
- Read the active-ingredient panel, not the brand name. Many night and PM products contain a first-generation antihistamine such as diphenhydramine or doxylamine. 4
- The 2023 AGS Beers Criteria advises avoiding first-generation antihistamines, benzodiazepines, and Z-drug hypnotics in most older adults, with named exceptions. 4
- A meta-analysis found Z-drugs associated with fractures and, for zolpidem, with injuries. Falls pointed the same way but did not reach statistical significance, and these were observational studies. 5
- Do not stop a benzodiazepine on your own. Abrupt withdrawal can be dangerous, and a taper is individualized.
- CBT-I still belongs in the conversation after 65, with adaptations for falls, mobility, nocturia, hearing, vision, and memory. 1 2 3
- The room can be made safer tonight without changing any medicine: a lit, clear path to the bathroom, a reachable light, and a phone within reach.
Sleep often becomes lighter and earlier with age. Waking during the night may become more common. Severe daytime sleepiness, repeated falls, major confusion, loud gasping, or hours of distress in bed should not be dismissed as “just aging.”
The safest first move is often a full sleep and medicine review, including products bought without a prescription.
Normal change does not explain every problem
The body clock may shift earlier, deep sleep may decrease, and sleep may become more fragmented. At the same time, apnea, restless legs, pain, nighttime urination, depression, heart or lung disease, neurocognitive illness, and medicines become more common. More time in bed can hide poor sleep or low daytime activity.
Ask what changed, when it changed, and what happens during the day. A new problem after a fall, infection, hospitalization, medication change, or change in memory needs evaluation.
The familiar “PM” aisle can carry real risk
Many night or “PM” products contain a first-generation antihistamine such as diphenhydramine or doxylamine. Ingredients can change, so read the active-ingredient panel rather than relying on the brand name.
The 2023 AGS Beers Criteria advises avoiding first-generation antihistamines in most older adults because of strong anticholinergic effects, reduced clearance, tolerance when used as a hypnotic, and risk that includes confusion, dry mouth, constipation, and other anticholinergic harm. The criteria apply to adults 65 and older but include setting and clinical exceptions. 4
Do not replace one product with another from this article. Bring the box or a photo of the label to a pharmacist or prescriber.
Benzodiazepines and Z-drugs need a careful review
The Beers Criteria advises avoiding benzodiazepines in most older adults because sensitivity is greater and risks include cognitive impairment, delirium, falls, fractures, and motor-vehicle crashes. It lists important exceptions for specific conditions. It also advises avoiding nonbenzodiazepine benzodiazepine-receptor agonist hypnotics, often called Z-drugs, because adverse events can resemble those of benzodiazepines while sleep benefits are modest. 4
A meta-analysis of observational studies found Z-drugs associated with fractures and, for zolpidem, with injuries. The signal for falls pointed the same direction but did not reach statistical significance and varied widely across studies. Because these were observational, confounding means the estimate is not a simple personal prediction. The decision still needs the person’s condition, dose, duration, other medicines, alcohol or cannabis exposure, and fall history. 5
If you take a benzodiazepine often, do not stop it on your own. Abrupt withdrawal can be dangerous. A clinician-guided taper, when appropriate, is individualized. The Nighttime Safety and Medicine Review is not a taper schedule.
A medicine inventory must include everything
List every prescription, over-the-counter product, supplement, alcohol exposure, and cannabis exposure. Include the dose or formulation if known and the actual time used. Do not list only products taken after dinner. A long-acting morning medicine can still affect the night, and a night product can affect the next day.
Older adults often take several medicines, which increases the chance of interactions and unwanted effects. The National Institute on Aging advises keeping a complete list and reviewing it with clinicians and pharmacists. 6
CBT-I still belongs in the conversation
Age does not remove access to behavioral treatment. AASM and ACP guidelines support CBT-I for chronic insomnia, and a brief behavioral trial showed benefit in older adults. 1 2 3
The plan may need adaptation for falls, mobility, pain, nighttime urination, caregiving, hearing, vision, and memory. A standard sleep-restriction worksheet without that review is not appropriate. The four-week CBT-I preparation guide therefore requires clinician guidance for frailty, falls, cognitive impairment, and other safety concerns.
Medicines marketed as alternatives are still medicines
AGS also publishes a companion Alternatives List for medicines named in the Beers Criteria. It sets out both medication and non-medication options for insomnia in older adults and leans toward behavioral treatment ahead of sedative-hypnotics. That is a resource for the prescriber conversation, not a self-selection menu. 7
Low-dose doxepin and dual orexin receptor antagonists may be reasonable prescriber conversations for selected people. They are not universally safe replacements. The indication, other medicines, breathing, cognition, fall risk, cost, and next-day response matter. This article makes no product ranking.
Make the room safer tonight without changing medicines
Clear the path from bed to bathroom. Add a reachable light that does not require walking in the dark. Keep a phone or call device within reach. Check loose rugs, cords, pets, unstable furniture, footwear, and whether the bed transfer is safe. These steps do not treat the cause of insomnia, but they reduce avoidable hazards while the cause is reviewed.
Acute confusion, a recent fall or injury, unsafe wandering, inability to transfer safely, or severe next-day impairment needs prompt clinical contact. Call 911 for serious injury, stroke-like symptoms, severe breathing trouble, inability to wake, or immediate danger.
Earlier timing can be normal; major impairment is not
An older adult may become sleepy earlier and wake earlier. That shift can be acceptable when daytime function is good. It deserves evaluation when it causes distress, social isolation, repeated unsafe waking, or a mismatch with essential caregiving or medical needs.
Frequent waking can also come from apnea, pain, urinary symptoms, heart or lung disease, RLS, temperature, noise, or medicine effects. Treating every awakening with a sedative may hide the cause.
Anticholinergic burden can come from several products
Diphenhydramine and doxylamine are found in some allergy, cold, and “PM” products. A person can accidentally take more than one anticholinergic ingredient under different brand names. Dry mouth, constipation, urinary retention, blurred vision, confusion, and falls may be read as separate aging problems.
The Beers Criteria’s avoid recommendation is a population-level prescribing aid with exceptions, not a command to abruptly stop a product. The safe action is to assemble the full list and ask a pharmacist or prescriber to identify duplicate ingredients and risks. 4
A fall review asks what happened before the fall
Record time, location, footwear, lighting, urge to use the bathroom, dizziness, sedation, alcohol or cannabis, and medicines taken. A fall after standing may raise a different question than tripping over a cord. New fainting, chest pain, weakness, speech change, or head injury changes urgency.
Do not wait for a second fall before discussing a sleep aid that causes next-day impairment.
Evidence about Z-drugs is not a personal risk calculator
The meta-analysis found a statistically significant association with fractures and, for zolpidem, with injuries. The estimate for falls pointed the same way but did not reach statistical significance and varied widely across studies. It drew largely on observational studies. People prescribed these medicines may differ from nonusers in ways that also affect risk. The result supports caution and review, not a claim that one pill caused one fall. 5
The review should include duration, dose, other sedatives, alcohol or cannabis, gait, blood pressure, cognition, nocturia, and whether the medicine still helps its intended target.
Deprescribing needs a plan and a destination
Stopping a familiar sleep medicine can bring withdrawal, rebound insomnia, anxiety, or return of the original problem. Benzodiazepines are especially unsafe to stop abruptly after regular use. A prescriber-guided plan may involve slow changes, monitoring, and behavioral support.
The destination matters. If apnea, pain, RLS, depression, or a late body clock is untreated, removing a medicine without treating the cause may leave the person worse. The review opens the conversation but never supplies a taper.
Behavioral treatment needs accessibility adaptations
CBT-I can be effective in older adults, but hearing, vision, memory, mobility, caregiving, and technology access affect delivery. Large print, a caregiver copy with consent, telephone support, fewer fields, or a clinician-guided brief format may be better than a dense digital program. 3
Planned time-in-bed reduction needs extra review when there is fall risk, frailty, nocturia, cognitive impairment, or a safety-critical task. The treatment remains possible for some people, but the standard public version is not enough.
Questions about newer options should stay comparative and personal
Ask what the medicine is approved to treat, what evidence exists in people your age and with your conditions, how next-day alertness was assessed, and what interactions matter. Ask whether cost, coverage, or fall risk changes the choice. Avoid the shortcut “newer means safer.”
Low-dose doxepin and orexin antagonists have evidence and labels for insomnia, but they are not interchangeable, and they do not erase apnea, balance, cognition, or polypharmacy concerns.
Involve a caregiver without erasing the older adult
When cognition or safety is changing, a trusted caregiver can help with the list and the room walkthrough, with the person’s consent whenever possible. Record who actually manages medicines. A pill organizer reduces some errors but does not reveal duplicate active ingredients across products.
Bring both the person’s goals and the caregiver’s observations. The aim is safer sleep and function, not simply fewer medicines.
Nocturia can turn a sleep plan into a fall plan
Repeated bathroom trips may come from fluid timing, medicines, urinary symptoms, diabetes, sleep apnea, heart problems, or other causes. Do not simply reduce fluids or move a medicine without guidance. Record the number of trips, urgency, dizziness on standing, and the path used.
A motion-activated night-light may help the path, but it does not explain the waking. If fainting, blood in urine, fever, severe pain, new weakness, or acute confusion occurs, seek urgency-matched care.
Check who is making the medicine decisions
Sometimes several prescribers, a caregiver, and more than one pharmacy are involved. Write who prescribes each item and which pharmacy has the most complete list. Ask one clinician or pharmacist to reconcile duplicates and interactions. 6
The opening conversation is not “Which pill should replace this one?” It is “What is each item for, what still helps, what may be harming sleep or safety, and what supervised plan addresses the original problem?”
Your next decision
Complete the review with the room walkthrough and every medicine or substance. Open the visit with: “I want to review what may be affecting sleep and fall risk before I add or change anything.” Do not stop a benzodiazepine, Z-drug, antihistamine, or psychiatric medicine on your own.
Print it: the Nighttime Safety and Medicine Review (PDF, two pages), or all eleven sleep worksheets in one file (PDF, 24 pages). The second page gives you a line to open the visit with, and it is not a taper schedule.
Frequently asked questions
Is a PM sleep product safe if it is sold without a prescription? Sold without a prescription does not mean low risk after 65. Many contain a first-generation antihistamine, which the Beers Criteria advises avoiding in most older adults because of anticholinergic effects, confusion, and fall risk. Bring the box or a photo of the label to a pharmacist.
My sleeping pill has worked for years. Should I stop it? Not on your own, and especially not a benzodiazepine, where abrupt stopping can be dangerous. Ask for a review of what each medicine is for, what still helps, and what supervised plan would address the original sleep problem.
Does waking at 4 a.m. mean something is wrong? Not by itself. The body clock often shifts earlier with age, and that can be acceptable when daytime function is good. It deserves evaluation when it causes distress, isolation, unsafe waking, or a clash with essential care.
Am I too old for CBT-I? No. Guidelines support CBT-I for chronic insomnia, and a brief behavioral version showed benefit in older adults. The delivery may need large print, telephone support, fewer fields, or a caregiver copy, and any planned reduction in time in bed needs extra review when there is fall risk or memory change.
Are the newer sleep medicines safer? Newer does not automatically mean safer. Ask what the medicine is approved to treat, what evidence exists in people your age with your conditions, how next-day alertness was measured, and what interactions and costs apply.
Related reading on NP FADY
- Sleep medications demystified
- You’re not weak. It may be rebound.
- Your legs won’t let you sleep: restless legs and iron
References
1. Edinger JD et al. Behavioral and psychological treatments for chronic insomnia disorder in adults: an American Academy of Sleep Medicine clinical practice guideline. Journal of Clinical Sleep Medicine, 2021. DOI 10.5664/jcsm.8986. DOI. PubMed.
2. Qaseem A et al. Management of Chronic Insomnia Disorder in Adults: A Clinical Practice Guideline From the American College of Physicians. Annals of Internal Medicine, 2016. DOI 10.7326/M15-2175. DOI. PubMed.
3. Buysse DJ et al. Efficacy of brief behavioral treatment for chronic insomnia in older adults. Archives of Internal Medicine, 2011. DOI 10.1001/archinternmed.2010.535. DOI. PubMed.
4. American Geriatrics Society Beers Criteria Update Expert Panel. American Geriatrics Society 2023 updated AGS Beers Criteria for potentially inappropriate medication use in older adults. Journal of the American Geriatrics Society, 2023. DOI 10.1111/jgs.18372. DOI. PubMed.
5. Treves N et al. Z-drugs and risk for falls and fractures in older adults - a systematic review and meta-analysis. Age and Ageing, 2018. DOI 10.1093/ageing/afx167. DOI. PubMed.
6. National Institute on Aging. Taking Medicines Safely as You Age. NIH, 2022. Source.
7. American Geriatrics Society. Alternative Treatments to Selected Medications in the 2023 American Geriatrics Society Beers Criteria. Journal of the American Geriatrics Society, 2025. DOI 10.1111/jgs.19500. DOI.
This article is for education. It does not diagnose a condition, replace individual care, or promise services. Do not start, stop, or change any medicine without your prescribing clinician. Reading this does not create a clinician-patient relationship. Evidence checked September 8, 2026.
If you or someone you know is in crisis
- Call 911 or go to your nearest emergency room for any life-threatening emergency.
- 988 Suicide & Crisis Lifeline — call or text 988, or chat at 988lifeline.org, available 24/7, free and confidential. En español: marque 988 y oprima 2, o envíe AYUDA al 988. Deaf or hard of hearing: 988 videophone (ASL) or TTY 711 then 988. Veterans: 988 and press 1, or text 838255.
- Crisis Text Line — text HOME to 741741.
- The Trevor Project (crisis support for LGBTQ+ young people) — call 1-866-488-7386, or text START to 678-678.
- National Sexual Assault Hotline (RAINN) — call 1-800-656-HOPE (4673) or text HOPE to 64673; free, confidential, 24/7. Online chat at RAINN.org/hotline.
- National Domestic Violence Hotline — call 1-800-799-SAFE (7233) or text START to 88788; 24/7, help in 200+ languages. Online chat at TheHotline.org. If your phone or computer may be monitored, calling from a safer device is an option.
- Riverside County — Inland SoCal Crisis Helpline 951-686-HELP (4357), 24/7 (Inland SoCal United Way / 211+, in partnership with RUHS-BH); Community Access, Referral, Evaluation and Support (CARES) Line 800-499-3008, 24/7.
- San Bernardino County — Access Unit (Behavioral Health Helpline) 888-743-1478, 24/7; Mobile Crisis/CCRT 800-398-0018 (24/7, all ages) or text 909-420-0560. Arrowhead Regional Medical Center (ARMC) has a dedicated walk-in adolescent psychiatric ER (ages 13–17).
- Children under 13 — call 911 for immediate danger, contact your county's mobile crisis team (they respond to all ages), or go to the nearest pediatric emergency room.
- California Peer-Run Warm Line (non-crisis — someone to talk to) — call or text 1-855-600-WARM (9276); daytime and evening hours, not a 24/7 line.
- NP Fady (non-emergency) — for routine scheduling or questions, call (909) 707-6261. This line is not monitored for emergencies.