The paradox of sleep medicines

Insomnia is one of the most common complaints among older adults. Doctors often turn to benzodiazepines (like temazepam, diazepam) or Z-drugs (like zolpidem, zopiclone). In the short term, they can help people fall asleep. But with chronic use, the balance tips: the risks start to outweigh the benefits.

Despite guidance that these medicines should be used for no more than 2–4 weeks, many older adults remain on them for years. That prolonged exposure carries consequences.

The risks of long-term use

1. Cognitive decline

• Memory impairment and reduced attention are well documented.

• Benzodiazepines and Z-drugs are linked to delirium, particularly after hospital admission or surgery.

• Observational studies suggest possible associations with increased dementia risk, though the evidence is mixed and confounded by insomnia itself.

2. Falls and fractures

• Sedation, impaired balance, and slower reflexes double the risk of falls.

• Hip fractures from falls in benzodiazepine users contribute directly to morbidity and mortality in late life.

3. Dependence and withdrawal

• Long-term users often develop tolerance, meaning the drug becomes less effective.

• Withdrawal can cause rebound insomnia, anxiety, or even seizures with abrupt cessation.

4. Daytime sedation and reduced function

• “Hangover” effects persist into the day: drowsiness, slowed reaction times, impaired driving ability.

• This contributes to accidents, reduced independence, and poorer quality of life.

5. Other concerns

• Respiratory depression in those with COPD or sleep apnea.

• Drug–drug interactions with opioids, alcohol, and other sedatives, amplifying harm.

Why older adults are especially vulnerable

Age changes how drugs behave:

• Slower liver metabolism and kidney clearance lead to drug accumulation.

• Higher brain sensitivity means smaller doses cause stronger effects.

• Polypharmacy increases the chance of dangerous interactions.

The result: side effects are amplified, and harms emerge at lower doses than in younger adults.

Alternatives and strategies

The good news: insomnia in older adults can often be managed without long-term sedatives.

Non-pharmacological treatments:

• Cognitive-behavioral therapy for insomnia (CBT-I) is the most effective long-term treatment.

• Sleep hygiene: regular sleep times, limiting caffeine, reducing screen exposure before bed.

• Relaxation and mindfulness-based approaches.

Deprescribing approaches:

• The Maudsley Deprescribing Guidelines recommend hyperbolic tapering: reduce doses gradually, in smaller steps as the dose gets lower, to minimize withdrawal symptoms.

• Combining tapering with CBT-I significantly improves success rates.

• Pharmacist-led interventions and shared decision-making increase adherence to deprescribing plans.

Take-home message

Sleeping pills can provide short-term relief, but in older adults, the long-term harms are substantial: falls, memory problems, dependence, and impaired quality of life.

For clinicians, the safer path is to limit duration from the start, review long-term users systematically, and offer structured tapering with non-drug sleep supports.

For patients and families, it’s important to ask: Is this medicine still helping, or is it quietly causing harm?