ABSTRACT: Insomnia is common among older adults, who should routinely be screened for sleep-related problems. Many older patients struggle to get a good night of sleep, and in fact, insomnia is more common in older adults than in younger persons.
In this article, we discuss the factors that control sleep, how sleep changes normally with age, and what goes wrong when insomnia develops. Some patients may present with symptoms of insomnia, but they may actually have another sleep disorder. Just a few decades ago, comorbid disorders were seen as an indication not to directly treat insomnia. Give patients who report symptoms of insomnia a sleep diary to be completed for approximately 2 weeks; it can provide a baseline assessment and can be helpful in monitoring treatment progress. While it is not always necessary to address underlying causes of insomnia before beginning treatment, it is important to address potential contributors that are reversible.
Unlike basic sleep hygiene education, CBT-I is a highly individualized treatment targeting the factors that maintain insomnia, which are somewhat different for each patient. Insomnia is common among older adults, and as healthcare providers we should routinely screen for sleep-related problems. When patients experience insomnia, consider other treatable sleep disorders, such as obstructive sleep apnea, restless legs syndrome, and periodic limb movement disorder.
It is associated with medical and mental health problems across the adult lifespan; untreated insomnia can negatively impact quality of life and predispose patients to exacerbation of other symptoms, such as pain and depression. We also provide an overview of other prevalent sleep disorders in older patients and outline practical recommendations for diagnosis, triage, referral, and treatment of older patients who present with insomnia. Understanding how these two underlying mechanisms interact will illuminate the factors that sustain chronic insomnia. Comorbid medical and mental health conditions can contribute to insomnia, and insomnia can exacerbate medical and mental health symptoms reflecting a bidirectional interaction.

Some patients will benefit from basic suggestions to improve sleep habits and reassurance that insomnia is a problem to be taken seriously.
Education about how sleep works and how insomnia develops is essential because the other components of treatment can present adherence challenges, and education can help the patient understand the rationale behind each recommendation.
In general, pharmacological therapies for insomnia are more often provided by primary care practitioners than by sleep specialists,39 and such therapies are appropriate for some patients. When patients experience insomnia, we should consider other treatable sleep disorders and recommend cognitive-behavioral therapy for insomnia whenever practical. Keep in mind that comorbid medical and mental health conditions can contribute to insomnia as well.
At least 70% of older adults with insomnia have comorbid medical or psychiatric disorders, use alcohol or drugs, or take medications that impact their sleep.25,26 Most older insomnia patients will present with insomnia in the context of other chronic problems. Generally, the contraindications for insomnia pharmacotherapy are more common among older patients because many sleep medications can increase the risk of falls, interact with other medications, and lead to confusion or cognitive problems; in addition, some may lead to physiological or psychological dependence.
While a change in circadian timing is a normal part of aging, it can contribute to difficulty in sleeping often resulting in symptoms of insomnia.
Attending to comorbid conditions and medications that contribute to insomnia is therefore a critical step in the management of insomnia symptoms. For example, daytime sleepiness resulting from OSA may lead to increased napping, which can exacerbate insomnia by decreasing sleep drive at night. A growing number of studies show that CBT-I is more effective than medications for the long-term management of insomnia,34,35 and we encourage you to identify a local specialist who can provide this treatment to your patients when referrals are necessary. What differentiates ASPD from insomnia is that adequate sleep is achieved, but it occurs at an undesirable time.
When OSA is suspected, hypnotic medication for insomnia should generally be avoided, and the patient should be cautioned about driving when sleepy. Nonetheless, accurate information about sleep-related issues is helpful for all insomnia patients.

Daytime napping affects the homeostatic drive for sleep at night, and oftentimes napping (planned or unintentional) becomes an important part of the clinical picture when we treat patients with insomnia. The influence of age, gender, ethnicity, and insomnia on Epworth sleepiness scores: a normative US population. Daytime consequences and correlates of insomnia in the United States: results of the 1991 National Sleep Foundation Survey.
Characteristics of insomnia in the United States: results of the 1991 National Sleep Foundation Survey. Sleep disordered breathing in an elderly community-living population: relationship to cardiac function, insomnia symptoms and daytime sleepiness. Primary versus secondary insomnia in older adults: subjective sleep and daytime functioning.
Cognitive behavioral therapy for insomnia improves sleep and decreases pain in older adults with co-morbid insomnia and osteoarthritis.
Evaluation of eszopiclone discontinuation after cotherapy with fluoxetine for insomnia with coexisting depression. Barriers to treatment seeking in primary insomnia in the United Kingdom: a cross-sectional perspective. Comparative effectiveness of cognitive behavioral therapy for insomnia: a systematic review.

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