Insomnia in Older Adults: A Holistic Approach

SPECIAL REPORT: GERIATRIC PSYCHIATRY PART 2

Emerging evidence demonstrates a link between poor-quality or insufficient sleep and accelerated aging as well as multiple medical illnesses such as diabetes, cardiovascular disease, and cancer.¹ Nearly 50% of older adults complain of trouble falling asleep or staying asleep, and up to 20% meet criteria for insomnia disorder.² Insomnia is common in older adults, in part due to age-related biological and physiological changes that contribute to alterations in sleep architecture and circadian rhythms.^2-5 Total sleep time and sleep efficiency decrease in addition to the amount of time spent in the stages associated with deep, restorative sleep (Figure).^4,5 Brain atrophy that occurs with normal aging contributes to phase advance of circadian rhythms and changes in the homeostatic regulation of the sleep-wake cycle.^3-5

The etiology of insomnia is complex, especially in older adults with comorbid conditions. Insomnia can coexist with medical conditions, psychiatric disorders, and other sleep-wake disorders. A variety of other factors may contribute to insomnia, such as the effects of certain medications and environmental and psychosocial factors. Some of these factors may not be modifiable, making management particularly challenging.

Psychiatrists and mental health clinicians can play a critical role in the emotional, cognitive, and physical health of their older adult patients by proactively assessing insomnia and related sleep complaints. Insomnia is a symptom associated with anxiety and mood disorders, and is a known risk factor for the development of depressive symptoms, suicidal ideation, and dementia.^4-6 A holistic approach to evaluating insomnia in older adults allows for management of symptoms and optimization of overall well-being.¹

This article will review the definition of insomnia and the considerations involved in assessing insomnia in older adults with multiple comorbidities. A clinical vignette will be used to highlight some of the complexities involved in assessing insomnia in older adults, necessitating a holistic approach to diagnosis and management.

Definition

Insomnia disorder is clinically defined by the DSM-5-TR as a disorder characterized by “a predominant complaint of dissatisfaction with sleep quantity or quality” in association with 1 or more of the following: (1) difficulty initiating sleep, (2) difficulty maintaining sleep either due to frequent awakenings or difficulty returning to sleep after awakenings, and (3) early morning awakening with inability to return to sleep.⁷ The disturbance must occur for at least 3 nights per week and persist for at least 3 months, despite ample opportunity for sleep. Symptoms must cause clinically significant distress or impairment in occupational, social, educational, or other important areas of functioning. The sleep disturbance cannot be attributable to the effects of a medication or substance use disorder, nor can it be adequately explained by a co-occurring mental health disorder, medical condition, or other sleep-wake disorder (Table 1). Insomnia disorder can be episodic (1-3 months), persistent (3 or more months), or recurrent (2 or more episodes occur within a period of 1 year). In addition to history gathering, the assessment may include the use of a sleep diary or clinical questionnaires such as the Pittsburgh Sleep Quality Index or Insomnia Severity Index.⁸

Clinical Vignette

“Zachary” is a 75-year-old man with a history of congestive heart failure, hypertension, atrial fibrillation, hyperlipidemia, diabetes, hypothyroidism, obstructive sleep apnea, spinal stenosis, prostate cancer, and posttraumatic stress disorder. Zachary takes multiple medications for his conditions and has done so for over a decade. Over the past 3 months, Zachary has been experiencing sleep disturbances nearly every night. As a result, he has been feeling more fatigued throughout the day, more irritable, and less interested in previous hobbies. Four months ago, Zachary underwent cardiac stent placement, and approximately 2 months ago, Zachary’s spouse passed away. He describes feeling lonely, depressed, and more anxious about things in general since the surgery. Zachary uses a continuous positive airway pressure machine at night but describes having difficulty falling asleep some nights due to “having a lot on [his] mind.” Most nights, Zachary wakes up several times during the night to use the bathroom but is unable to fall back to sleep. Zachary has tried taking melatonin, drinking chamomile tea, and using a white noise machine with relaxing seascape sounds, but sleep has not improved. Zachary reports falling asleep while watching television and recently had a car accident after falling asleep while driving. Because of this, Zachary has been having difficulty keeping up with medical appointments due to daytime sleepiness and being afraid to drive. He values his independence and worries that lack of sleep will continue to have negative effects. Zachary asks his psychiatrist for help and says, “I just want to get a good night’s sleep so I can function.”

Discussion

The vignette illustrates the complexities involved in assessing insomnia in an older adult with multiple comorbidities. Zachary is clearly experiencing distressing symptoms, including mood changes and daytime sleepiness. Zachary has fallen asleep behind the wheel, which raises safety concerns. Zachary’s medical, psychiatric, and psychosocial history, such as recent cardiac surgery and the death of a spouse, are all potential contributing factors. A holistic approach to assessing insomnia in older adults will focus on what matters most to the patient and help guide the subsequent steps of symptom management.

A first step in assessing insomnia involves taking an inventory of the patient’s sleep concerns by allowing them to describe the onset and duration of symptoms and the impact on their daily life. This will allow the clinician to unfold pertinent details about the patient’s medical and psychosocial history, allowing for a review of possible contributing factors (Table 2).^4,7,8

Asking patients about the strategies they previously used to manage their symptoms may provide insight into the patient’s priorities, belief system, and understanding of insomnia.

Next, have a discussion with the patient about what matters most in terms of their treatment goals. In ruling out the presence of other sleep disorders, discuss the possibility of further diagnostic testing or specialist referrals. Review the different treatment options and engage in shared decision-making with the patient to ensure the next steps in symptom management align with their goals and preferences.

Management

The American Academy of Sleep Medicine and other professional organizations recommend cognitive behavior therapy for insomnia (CBT-I) as the first-line and gold standard treatment for insomnia.⁹ CBT-I is a multicomponent therapy that focuses on addressing the perpetuating factors contributing to insomnia. It is typically delivered over the course of 6 to 8 in-person sessions, and there are online and digital tools available for those unable to attend in-person therapy. However, this treatment is not easily accessible either due to lack of transportation or lack of access to technology required for the online and digital versions.^10,11 Brief behavioral treatment for insomnia is an alternative to CBT-I that focuses on behavioral interventions, such as sleep restriction and stimulus control rather than the cognitive aspects of CBT-I.⁸

Pharmacological methods are also available and may be utilized in conjunction with cognitive and behavioral interventions. The clinician should engage in a shared-decision-making discussion with the patient regarding the risks, benefits, and adverse effects of medications.

Clinicians will encounter challenges when selecting medications for insomnia in older adults because of the lack of consensus among professional societies regarding safety and efficacy. Many of the medications used to treat insomnia, even those that have been FDA approved, are considered potentially harmful in older adults, according to the American Geriatrics Society 2023 updated Beers Criteria, making medication selection challenging for some clinicians.^12,13 When prescribing medications, clinicians can become overwhelmed by the litany of adverse effects associated with various medications. In older adults, one must consider polypharmacy, drug-drug interactions, and medical comorbidities that may increase the risk of adverse effects. However, one must also remember to incorporate the concept of what matters most, taking an individualized approach to each patient.^4,11,13-15 This can help determine the best course of treatment for an individual patient based on their psychosocial circumstances, comorbidities, and their overall goals of care. Table 3 describes the varied components of CBT-I to help make the most informed decision.¹⁰

Concluding Thoughts

Diagnosing insomnia in older adults is challenging because of the age-related changes that occur in sleep physiology and circadian rhythms. There are often multiple factors that contribute to insomnia, such as the effect of medications, co-occurring medical and mental health conditions, or other sleep-wake disorders. Psychiatrists and mental health clinicians play a critical role in the overall health and well-being of older adults by assessing and managing insomnia, which is associated with multiple adverse health outcomes. A thorough sleep history is almost as important as a thoughtful discussion with the patient about their health beliefs, goals, and preferences. Management options include cognitive and behavioral therapies in addition to pharmacological treatment, with evidence for both short-term and long-term sleep complaints.^14,16 Decision-making about treatment can be challenging because of the lack of consensus regarding pharmacological interventions and lack of access to certain information and resources. Table 4 provides a list of commonly prescribed medications that are FDA approved for insomnia.^{11,13,14,16-18}

Dr Dix is an assistant professor of psychiatry in the Department of Psychiatry at Yale University School of Medicine in New Haven, Connecticut. She is a geriatric and interventional psychiatrist and serves as the medical director for the Inpatient Geriatric Psychiatric Unit at Yale New Haven Hospital-St Raphael Campus. Dr Srinivasan is a clinical professor of neuropsychiatry and behavioral science in the Department of Neuropsychiatry & Behavioral Science and vice chair of medical staff affairs at Behavioral Health Midlands at Prisma Health, both at the University of South Carolina School of Medicine in Columbia. Dr Tampi is a professor and chair of the Department of Psychiatry at Creighton University School of Medicine and Catholic Health Initiatives Health Behavioral Health Services, both in Omaha, Nebraska. He is also an adjunct professor of psychiatry at Yale School of Medicine and a member of the Psychiatric Times editorial board.

References

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17. Drugs@FDA: FDA-approved drug products. FDA. Accessed August 12, 2025. https://www.accessdata.fda.gov/scripts/cder/daf/index.cfm

18. De Crescenzo F, D’Alò GL, Ostinelli EG, et al. Comparative effects of pharmacological interventions for the acute and long-term management of insomnia disorder in adults: a systematic review and network meta-analysis. Lancet. 2022;400(10347):170-184.