Insomnia in Older Adults: Safer Medication Choices

More than one in three adults over 65 struggle with insomnia. It’s not just trouble falling asleep-it’s waking up too early, lying awake for hours, or feeling exhausted all day. For older adults, the stakes are higher. A bad night’s sleep doesn’t just leave you tired; it increases the risk of falls, memory problems, and even long-term disability. And while many turn to sleep meds, not all are created equal. Some are outdated, dangerous, and still widely prescribed. The good news? Safer, smarter options exist.

Why Older Adults Need Different Sleep Medications

As we age, our bodies change. The liver and kidneys don’t process drugs as quickly. This means medications stick around longer, increasing the chance of side effects like dizziness, confusion, or next-day grogginess. Older adults often take multiple medications for heart issues, diabetes, or arthritis. Mixing these with sleep drugs can be risky. A 2018 study found that combining sleep meds with other central nervous system depressants-like painkillers or anxiety meds-raises fall risk by 70%.

The old go-to drugs for insomnia-benzodiazepines like lorazepam or triazolam, and the so-called "z-drugs" like zolpidem (Ambien)-were never meant for long-term use in seniors. The American Geriatrics Society warned back in 2012: avoid these. They increase the chance of hip fractures by up to 50% and double the risk of confusion. Even a single dose can leave someone unsteady on their feet the next morning.

The Newer, Safer Options

Thankfully, newer medications have been developed with older adults in mind. These aren’t just "newer"-they’re designed to work differently and with fewer risks.

Lemborexant (brand name Dayvigo) is one of the most promising. It works by blocking orexin, a brain chemical that keeps you awake. Unlike older drugs that shut down brain activity broadly, lemborexant gently nudges the brain toward sleep. In clinical trials with adults over 65, it reduced the time to fall asleep by 15 minutes and added over 40 minutes of total sleep-without the grogginess. A 2025 study showed users had 18% less disability progression over a year compared to those on benzodiazepines. Side effects? A small number felt dizzy at first, but it usually faded within two weeks.

Suvorexant (Belsomra) works the same way but has a shorter half-life. It’s effective for sleep onset and maintenance, with less next-day impairment than z-drugs. It’s a solid option if lemborexant isn’t covered by insurance.

Ramelteon (Rozerem) is another low-risk choice. It mimics melatonin, helping reset the body’s internal clock. It’s especially helpful for seniors who wake too early or have trouble falling asleep at the right time. It doesn’t cause dependence, doesn’t affect balance, and has almost no risk of memory issues. The downside? It doesn’t add huge amounts of sleep-just 20-25 minutes on average. But for someone who’s been sleeping only 4 hours a night, that’s meaningful.

Low-dose doxepin (Silenor) is perhaps the most overlooked gem. At 3 to 6 mg-just 1/20th the dose used for depression-it blocks histamine receptors that keep you awake. It’s FDA-approved specifically for sleep maintenance insomnia. In real-world use, 58% of seniors report moderate improvement in staying asleep, and only 12% feel groggy the next day. It costs about $15 a month as a generic, making it one of the most affordable safe options.

What to Avoid

Some medications still get prescribed out of habit-even though guidelines say not to.

Zolpidem (Ambien), eszopiclone (Lunesta), and zaleplon (Sonata) are still widely used. But data shows they cause next-day drowsiness in over a third of older adults. Worse, 8% of users report sleep-related behaviors: sleepwalking, making phone calls, or even driving while not fully awake. These aren’t myths-they’re documented risks.

Benzodiazepines like diazepam, lorazepam, and temazepam are even riskier. They’re linked to higher rates of falls, fractures, and dementia. A 2024 Medicare analysis found that 7.2 million older adults still got benzodiazepines for sleep-despite clear warnings from experts. These drugs should be avoided unless absolutely necessary and only for a few days.

What Works Best? A Quick Comparison

Non-Medication First: CBT-I

Before any pill, experts agree: try Cognitive Behavioral Therapy for Insomnia (CBT-I). It’s not just a "therapy"-it’s a structured program that teaches you how to fix sleep habits. Studies show it works better than pills for long-term results. It helps people fall asleep faster, stay asleep longer, and feel more rested-even without drugs.

But here’s the problem: only 12% of older adults are ever offered CBT-I. Most doctors don’t have time, or insurance doesn’t cover it. Digital CBT-I apps like reSET-O (FDA-cleared in 2023) are changing that. They’re accessible, affordable, and proven effective. If you’re considering a sleep med, ask your doctor: "Can I try CBT-I first?"

How to Talk to Your Doctor

If you’re on a sleep med right now, don’t stop cold turkey. Talk to your doctor about switching. Here’s what to say:

• "I’ve been having trouble sleeping, and I’m worried about falling or feeling foggy in the morning."
• "I’d like to explore safer options like low-dose doxepin or ramelteon."
• "Can we try CBT-I before adding or changing meds?"
• "Can we set a plan to reduce or stop this medication?"

Doctors need to know you’re concerned-not just asking for a stronger pill. Many are unaware of the latest guidelines. Bring a printout of the American Geriatrics Society Beers Criteria if needed. Ask for a sleep diary to track your patterns. And insist on a fall risk assessment-it’s simple, free, and vital.

Real Stories, Real Results

One 72-year-old man in Ohio switched from zolpidem to low-dose doxepin after a fall. "I used to wake up feeling like I’d been hit by a truck," he said. "Now I sleep through the night and get up without help." A woman in Florida tried lemborexant after years of bad sleep. "It didn’t make me feel drugged," she wrote. "I just felt like I finally got the rest I needed." But cost is a barrier. Lemborexant and suvorexant are expensive without insurance. Doxepin and melatonin are cheap and effective. If you’re on a fixed income, ask your pharmacist about generic alternatives. Many pharmacies offer $4 monthly generics.

What’s Next?

New drugs are coming. Danavorexton, a selective orexin 2 receptor agonist, is in late-stage trials and could offer even better safety for seniors by 2026. But the real shift isn’t in new pills-it’s in how we think about sleep. We’re moving away from "quick fix" drugs and toward sustainable, safe, and personalized care.

The goal isn’t to sleep 8 hours. It’s to wake up feeling safe, clear-headed, and ready for the day. That’s possible-with the right choices.