Sleep medicines in dementia

Poor sleep is one of the hardest parts of dementia for families. The person may wake again and again, wander at night, or sleep all day and stay up all night. When a caregiver is worn out, a sleeping pill can seem like the answer.

Some sleep medicines can help a little. But many common ones make confusion, falls and memory worse in a person living with dementia. This page explains what the research shows, which medicines have the most support, and which ones to avoid.

Why sleep changes in dementia

Many people with Alzheimer's have sleep changes. They are more common and more severe than in older adults without dementia, and they tend to get worse in later stages. In the late stage, a person may spend about 40% of the night lying awake.⁴ Scientists think the disease itself damages the brain areas that run the sleep-wake cycle.⁴

Other problems can add to this. A doctor should check for things that can be treated, such as depression, restless legs, sleep apnea (breathing that stops and starts during sleep) and pain.⁴ Experts advise not giving memory medicines like donepezil at bedtime. Ask the doctor about the best time of day for each medicine.⁴

For the full picture of night waking, day-night mix-ups and caregiver sleep, see sleep problems in dementia and sundowning.

Non-drug steps come first

Experts agree that non-drug steps should come before any sleep medicine.⁴ A national guideline from England suggests a plan tailored to the person. It includes learning good sleep habits, getting daylight, exercise, and activities the person enjoys.⁶

Suvorexant (Belsomra)

Suvorexant is a prescription sleep medicine sold as Belsomra. It belongs to a group called orexin receptor antagonists. Orexin is a brain chemical that helps keep you awake. These medicines block it, which lets sleep come more easily.⁴

The FDA approved Belsomra for insomnia (trouble falling asleep or staying asleep) in 2014.² In early 2020, the FDA added the results of a study in people with mild to moderate Alzheimer's disease to its label. This was a label update, not a separate new approval.² The Alzheimer's Association lists it as the only sleep medicine whose FDA approval covers insomnia in mild to moderate Alzheimer's, as of October 2026.⁴

What the study showed. The study included 285 people aged 50 to 90 with Alzheimer's disease and insomnia. Half took suvorexant and half took a placebo (a look-alike pill with no medicine) for four weeks. Sleep was measured overnight in a sleep lab. People taking suvorexant slept longer and spent less time awake after first falling asleep.¹

A Cochrane review pooled this study with a similar one of another orexin medicine. On average, these medicines added about 28 minutes of sleep a night. They cut time awake in the night by about 16 minutes.³ Side effects overall were probably not much more common than with placebo.³

What this means in daily life. Half an hour more sleep is real, but modest. The person will probably still wake at night. The study lasted only four weeks and included only people with mild to moderate Alzheimer's.^1,3 We do not know how well it works over months, or in other types of dementia.

Side effects and warnings. In the Alzheimer's study, a few more people on suvorexant had sleepiness (4% vs 1%) and falls (2% vs 0%).¹ The label also warns about:¹

• Next-day drowsiness and slower reactions, including unsafe driving
• Sleepwalking or other complex actions while not fully awake
• Brief inability to move or vivid dream-like images when falling asleep or waking
• Worsening depression or new thoughts of suicide
• Possible effects on breathing in people with lung disease or sleep apnea (it was not studied in severe cases)

People with narcolepsy should not take it.¹ Because it causes drowsiness, older adults have a higher risk of falls.¹ Your doctor starts low and goes slow.

Other orexin medicines

Two other medicines in the same group, lemborexant (Dayvigo) and daridorexant (Quviviq), are approved for insomnia in adults. Lemborexant was tested in a small Alzheimer's study that was part of the Cochrane review.³ A study of daridorexant in people with mild cognitive impairment or mild to moderate Alzheimer's is still recruiting. Results are not expected before 2027.¹²

Trazodone

Trazodone is an older antidepressant. Doctors often use low amounts of it for sleep. This is "off-label," meaning the FDA has not approved it for sleep.

Only one small trial has tested it for sleep in dementia. It included 30 people with Alzheimer's disease and lasted two weeks. People on trazodone slept about 42 minutes more per night. The Cochrane review rated this evidence as low certainty, so the true effect could be quite different.³ Limited research No serious side effects were reported in that small trial.³ Still, like other sedating medicines, it can cause drowsiness that raises the risk of falls.⁴

Melatonin: what the evidence says

Melatonin is a hormone your body makes in the evening. In the U.S., it is sold as a dietary supplement without a prescription.⁵

For sleep in Alzheimer's, it probably does not help much. The Cochrane review looked at five melatonin trials in people with Alzheimer's disease. Melatonin made little or no difference in total sleep time. The average gain was about 11 minutes, and the true effect could be zero.³ Limited research The review found no evidence that melatonin or a related prescription drug, ramelteon, helps.³

Guidelines agree:

• England's national dementia guideline says not to offer melatonin for insomnia in people with Alzheimer's disease.⁶
• The AASM suggests doctors avoid melatonin for older adults with dementia whose sleep has no regular pattern.⁷

Product quality is a concern. Because melatonin is a supplement, the FDA does not check it the way it checks medicines. In one study, most melatonin products did not contain the amount on the label, and about 1 in 4 contained serotonin. In a 2023 study of gummies, 22 of 25 were labeled wrong. One had almost three and a half times the listed amount.⁵

Older adults. Melatonin may last longer in older bodies, which can cause daytime sleepiness. People who take blood thinners or have epilepsy should use it only with a doctor's guidance.⁵

One exception: acting out dreams. Some people with Lewy body dementia or Parkinson's disease have REM sleep behavior disorder. They kick, punch or shout as they act out dreams. For this problem, the AASM suggests doctors consider melatonin.⁸ Read more about Lewy body dementia.

Sleep medicines to avoid

Some sleep aids are especially risky for a person living with dementia. Many are sold over the counter, so families may not think of them as "real" medicines.

Why these matter. In older adults, sleep medicines raise the risk of falls and broken bones and of more confusion. They can also make it harder for a person to care for themselves. They often do not improve overall sleep quality.⁴ For benzodiazepines and Z-drugs, no trials have tested them in people with dementia, so the balance of risks and benefits is unknown.³ The AASM strongly advises against sleep-promoting medicines for older adults with dementia whose sleep has no regular pattern, mainly because of falls and other harms.⁷

Z-drugs. In 2019, the FDA added its strongest warning, a boxed warning, to zolpidem, eszopiclone and zaleplon. People had been injured or killed while sleepwalking, sleep driving or doing other things while not fully awake.⁹

Antipsychotics. All antipsychotics carry a boxed warning that older adults with dementia-related psychosis have a higher risk of death when treated with them.¹¹ They are not approved for sleep. Even so, quetiapine and similar drugs are sometimes given for sleep problems.⁴ If one has been prescribed for the person, ask why and whether it is still needed. For people with Lewy body dementia, some antipsychotics can cause severe reactions. See medicines for agitation and behavior.

For a wider list, including bladder medicines and other drugs that can cloud thinking, see medicines that can worsen memory. For sleep medicines in general, see sleep medicines: what to know.

If a sleep medicine is used

Sometimes non-drug steps are not enough, and the person and caregiver are not getting the rest they need. A sleep medicine may be worth trying, with a clear plan.

1. Rule out other causes first. Ask the doctor to check for pain, infection, depression, restless legs and sleep apnea.⁴
2. Ask about benefits, risks and other choices before starting any new medicine.⁴
3. Start low and go slow. Experts advise beginning with a small amount and raising it slowly if needed.⁴
4. Keep a sleep log. Write down bedtime, night waking, falls and daytime sleepiness. A behavior diary works well.
5. Make the bedroom safe. Use night lights, clear paths to the bathroom and think about fall risks. See preventing falls.
6. Plan a review. Experts suggest trying to stop the medicine once a regular sleep pattern returns.⁴ Ask when you will check whether it is still needed.

A pharmacist can review every medicine and supplement the person takes, including over-the-counter products. Bring them all in one bag to the visit. See managing medicines at home.

Questions to ask the doctor

Before starting a sleep medicine

• Could pain, an infection, depression or sleep apnea be causing the poor sleep?
• Could any of the person's current medicines, or their timing, be keeping them awake?
• What non-drug steps should we try first, and for how long?

About a specific medicine

• How much extra sleep can we expect from this medicine?
• What side effects should we watch for, especially falls and next-day sleepiness?
• Does it mix safely with the person's other medicines and supplements?
• Is it covered by our Medicare drug plan?

About what they take now

• Is the person taking any over-the-counter sleep aid, antihistamine or "PM" product we should stop?
• Is any current medicine a benzodiazepine, Z-drug or antipsychotic? Is it still needed?
• If we want to stop a medicine, how do we do it safely?

Caregiver sleep matters too

When the person you care for is up at night, you lose sleep too. Over time, this can harm your health and patience. Ask family, friends or a respite care service to cover some nights. An adult day care program can help keep the person active during the day, which may improve night sleep. If you have trouble sleeping even when you can, CBT for insomnia is the first-choice treatment for adults with chronic insomnia.⁵ See also caregiver stress and burnout.

Education only. This page is general information written from the sources listed. It is not medical, legal or financial advice and does not replace a doctor, therapist or lawyer who knows your situation. How we write and check pages.