Over-the-Counter Sleep Aids: Why Doctors Urge Caution After 65

Here is a label worth a second look. Pick up a nighttime sleep aid at the drugstore, and there’s a good chance the active ingredient is an antihistamine, the same kind of medicine used for allergies. MedlinePlus, the National Institutes of Health’s consumer health site, notes that most over-the-counter sleeping pills contain antihistamines.

Two of them are diphenhydramine and doxylamine, and MedlinePlus is unusually direct about both. It says diphenhydramine “generally should not be used in older adults,” except to manage serious allergic reactions, because it isn’t as safe or effective as other medicines. It gives the same reasoning for doxylamine. For both, it advises anyone 65 or older to talk with a doctor about the risks and benefits.

Why These Medicines Are on the “Avoid” List

The American Geriatrics Society publishes the Beers Criteria, a list doctors use to spot medicines that are usually best avoided after 65. Its 2023 update puts both diphenhydramine and doxylamine on the “avoid” list, with a strong recommendation. The reasons it gives:

• They stay in the body longer. The body clears these medicines more slowly with age.
• They stop working as well. Tolerance develops when they’re used for sleep.
• They have side effects. The Beers Criteria lists confusion, dry mouth, and constipation, among others. MedlinePlus lists drowsiness for both medicines and dizziness for diphenhydramine, and says to call your doctor right away if you have vision problems or trouble urinating.
• They add up. Both medicines are strongly anticholinergic. The Beers Criteria notes that cumulative exposure to anticholinergic drugs, whether from long-term use or from taking several at once, is associated with a higher risk of falls, delirium, and dementia.

The Memory Question

Research such as a 2015 study in JAMA Internal Medicine has examined that link. Researchers followed 3,434 people 65 and older in the Seattle area who didn’t have dementia when the study began, for an average of about seven years. They found that higher cumulative use of anticholinergic medicines was associated with an increased risk of dementia. First-generation antihistamines, the group that includes diphenhydramine and doxylamine, were among the most commonly used types.

The higher risk was clear in the heaviest users, roughly the equivalent of a daily dose for more than three years. Because it was an observational study, it can’t prove the medicines cause dementia. The researchers called for more awareness of this potential risk among doctors and patients.

Many anticholinergic medicines need a prescription. If you take one, don’t stop it on your own. Talk to your doctor first.

Hidden in “PM” Products

MedlinePlus lists many combination products that contain diphenhydramine, including pain relievers sold as “PM” versions, which pair it with acetaminophen, ibuprofen, naproxen, or aspirin, and some nighttime cold medicines.

That makes it easy to take a double dose without meaning to. The Drug Facts label on a diphenhydramine sleep aid warns against using it with any other product that contains diphenhydramine, even one used on the skin.

What the Label Says

If you still use one of these products, the label carries advice that’s easy to skip past:

• Two weeks is the limit. A typical diphenhydramine sleep aid label says to stop and ask a doctor if sleeplessness persists continuously for more than two weeks, because insomnia may be a symptom of a serious underlying medical illness. MedlinePlus says to call your doctor if you feel you need doxylamine for longer than two weeks.
• Check your other medicines. Diphenhydramine sleep aid labels say to ask a doctor or pharmacist before use if you take sedatives or tranquilizers.
• Skip alcohol. MedlinePlus warns that alcohol can add to the drowsiness these medicines cause.
• Wait before driving. MedlinePlus advises not driving a car or operating machinery until you know how the medicine affects you.
• Check your health history. MedlinePlus says to tell your doctor before using diphenhydramine if you have glaucoma, trouble urinating because of an enlarged prostate, or lung conditions such as emphysema or chronic bronchitis. For doxylamine, it adds conditions such as asthma, ulcers, heart disease, high blood pressure, seizures, and an overactive thyroid.

What Helps Instead

Sleep changes are common with age. MedlinePlus notes that many people find it harder to fall asleep and wake up more often as they get older.

Start with your doctor. According to MedlinePlus, treating insomnia often begins by looking for causes such as pain, nighttime bathroom trips, acid reflux, depression or anxiety, and medicines that interfere with sleep.

Ask about CBT-I. The American College of Physicians strongly recommends cognitive behavioral therapy for insomnia, or CBT-I, as the first treatment for adults with chronic insomnia. MedlinePlus describes it as a form of talk therapy that may help you gain control over your sleep.

Try a few habit changes. MedlinePlus suggests:

• Going to bed and waking up around the same time each day
• Avoiding caffeine and alcohol in the evening, and heavy meals within two hours of bedtime
• Skipping daytime naps
• Walking or exercising for at least 30 minutes on most days
• Keeping your bedroom quiet, dark, and at a comfortable temperature
• Getting up and moving to another room for a quiet activity if you can’t fall asleep within 30 minutes

The Bottom Line

The American Geriatrics Society advises avoiding diphenhydramine and doxylamine after 65, and MedlinePlus advises against them for older adults in most cases.

If you’ve been reaching for one, bring the bottle to your next appointment. A better night’s sleep may start with a conversation.