Sleep aids and medicines: the options, in order
The short answer
- Start with the free steps, done together. (A fixed wake time, daylight at the right hour for them, a daily walk, one short nap.) The two-week plan.
- Thinking of melatonin? Ask the doctor first, and expect little. (It shows little or no effect for sleep in dementia. Acting out dreams is the exception.)
- Do not give Tylenol PM, Advil PM, ZzzQuil or Unisom. (They add confusion, falls and delirium.)
- Offered a sleep medicine? Ask, "What is the fall risk?" (Even those with dementia evidence carry fall risk.) The questions to ask.
- On a prescribed sleep medicine? Do not stop it suddenly. (Ask the prescriber for a plan.)
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: a two-week plan 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 later dementia.)
- Nightly sleeping pills are a poor trade. (Over 60: about 25 more minutes of sleep, but nearly five times the memory and confusion problems.)
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 daytime steps that help night sleep, 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, six carer sessions beat usual care; we could not confirm it elsewhere.)
Next: things families buy or try
Thinking of melatonin? Ask the doctor first, and expect little
- For sleep in dementia, it shows little or no effect. (Cochrane review, 2020, low certainty. No serious side effects in the trials.)
- Two major guidelines say not to use it for this. (US sleep doctors, weakly, and the UK's NICE. One study found harm to mood and daytime function.)
- The exception: acting out dreams (shouting, punching or falling out of bed while asleep). (This is REM sleep behavior disorder, common in Lewy body dementia. Melatonin may help here. Tell the doctor.)
- If the doctor says try it, buy a bottle marked USP Verified or NSF Certified. (Those marks mean an independent lab checked it. A 2023 test found 22 of 25 melatonin gummies mislabeled.)
- Light box: only if they cannot get outside, and tell the doctor. (Evidence: thin and mixed. The right hour depends on the kind of waker: light.)
- Weighted blanket: ask the doctor first, and only if they can push it off alone. (One small study. Risks: being trapped, heat, and trouble for the frail or short of breath.)
- 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. (The geriatric safety list says to avoid them 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. (A US guideline strongly advises against sleep medicines in dementia with irregular sleep: harms outweigh gains.)
- Trazodone: ask, "What is the fall risk?" (Evidence: thin. In nursing homes, new users had fall injuries as often as on Valium-type drugs. Generic.)
- Suvorexant (Belsomra): ask about falls and next-morning drowsiness. (About 28 more minutes a night. More falls; its label warns of sleepwalking-type acts and dream-like hallucinations. Brand only.)
- Lemborexant (Dayvigo): ask what the evidence is in dementia. (Same family as Belsomra; one small Alzheimer's trial. Its label warns of more falls. Brand only.)
- Mirtazapine: ask why, if it is offered for sleep. (In a small Alzheimer's trial, nights did not improve and days got sleepier. It can lower blood sodium.)
- Ambien-type or Valium-type sleeping pills: ask what else could be tried. (The geriatric safety list says to avoid them: more confusion, delirium, falls and fractures, for little extra sleep.)
- An antipsychotic offered "to help them sleep"? Ask, "Is this for sleep? What should we try first?" (Such as quetiapine (Seroquel). A higher risk of death in dementia; guidelines keep them for severe distress, 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 can disturb sleep; ask about a morning dose. Evening water pills mean night toilet trips.) Finding the cause.
- "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?"