Diagnosis, treatment, and associated outcomes of later-life insomnia: a narrative review

Abstract

Insomnia is highly prevalent in older adults and is associated with a range of health outcomes. Over the past 10 years, there have been several reviews of the literature concerning insomnia and its outcomes among older individuals; however, there is a need for an updated review examining the emerging themes of research in this space to guide clinical practice and research. Accordingly, in this narrative review, we highlight recent research on insomnia in older adults, documenting the evolution of knowledge regarding insomnia and its consequences as people age. Our review describes trends in the prevalence of insomnia and related symptoms in older adults, as well as potential factors contributing to these trends. We also highlight the growing recognition of insomnia-associated outcomes, specifically focusing on brain and heart health. Given challenges in and barriers to identifying and ultimately treating insomnia, we describe shifts in the ways insomnia is treated with applicability to older adults, including through digital therapeutic modalities that have the potential to increase access to evidence-based behavioral therapies. Our review highlights significant advancements in the understanding of insomnia’s role in older adults’ health and underscores critical priorities for future research.

Statement of Significance

Insomnia is highly prevalent in older adults and is associated with a growing scope of adverse health outcomes. While barriers exist to its diagnosis and appropriate treatment in older persons, advancements in the field of sleep medicine, such as expanded pharmacological options and digital therapeutics for behavioral sleep treatments, may help address the unmet need for care. Our narrative review seeks to trace these developments in the hopes of spurring future research to address insomnia in the growing population of older adults.

Introduction

The population of older adults is growing at an unprecedented rate in the United States and globally [1]. Sleep disturbances are prevalent among older people, and insomnia is among the more common sleep disorders [2–4]. Growing evidence ties insomnia to poor health outcomes in older adults, including in the physical [5], mental [6, 7], and cognitive [8] domains of health. Thus, understanding insomnia in older adults, as well as its associated outcomes and treatment, is of increasing public health importance. There have been numerous reviews concerning sleep and insomnia in older populations [4, 9–12]. However, with the increased recognition of its links to health outcomes in later life, and the new technologies and pharmacological therapeutics that have emerged for insomnia treatment, an updated review of insomnia in older adults is warranted.

There are well-documented age-related changes in the quantity and quality of sleep across the human lifespan. In a meta-analysis including 65 studies of n = 3577 subjects aged 5–102 years, Ohayon et al. found that as people age, their sleep becomes shorter and more fragmented, and less time is spent in slow-wave and rapid eye movement sleep and more time in lighter sleep stages [13]. While these changes appear even in healthy individuals [13], other factors contributing to these altered sleep patterns include the presence of comorbid health conditions [14], various medications used and respective doses [15], polypharmacy [16], and changes in lifestyle patterns, including the transition to retirement [17], caregiving [18], and bereavement [19]. Along with normative age-related changes in sleep and sleep architecture, a sizable proportion of older adults experience a clinical level of insomnia, which is commonly defined based on reports of difficulty initiating sleep, maintaining sleep, and/or waking up too early with an inability to return to sleep, with adverse effects on daytime functioning [20].

Here, we present a narrative review of the literature on insomnia in older adults, highlighting the growing recognition of links between later-life insomnia and an array of health outcomes. We first discuss the epidemiologic literature concerning temporal trends in insomnia prevalence in older adults. Next, we describe recent findings linking insomnia to health outcomes, including cardiovascular disease and cognitive impairment and dementia. We next review clinical issues related to the diagnosis and potential underdiagnosis among older adults. Finally, we discuss behavioral and pharmacologic treatments for insomnia, including recent developments in both. The ultimate goal of this review is to provide an updated overview of the growing recognition of the importance of insomnia in older adults to guide future directions in research and practice.

Methods

We conducted a narrative review of the literature on insomnia in older adults published over the past decade. Our primary goal was to synthesize major conceptual and clinical developments—particularly in diagnosis, treatment, and the health consequences of insomnia—to highlight important gaps and generate directions for future research. While there have been extensive reviews on insomnia and older adults [4, 9–12], most focus broadly on age-related sleep changes or insomnia disorder in older adults, often without addressing recent developments in health outcomes research, digital therapeutics, or newer pharmacologic options. Our review adds to this literature by synthesizing more recent findings from the past decade, with a particular emphasis on emerging evidence linking insomnia with cognitive and physical health, and highlighting underexplored areas for future research. To achieve this goal, we chose to conduct a narrative review over a systematic or scoping review in order to provide a more flexible integration of evidence across disciplines.

Before beginning the literature review, we identified two key topics to address: (a) trends in the prevalence and associated health outcomes of insomnia in older adults and (b) recent advancements in the diagnosis and treatment of insomnia specifically tailored for older adults. We focused on published peer-reviewed studies, primarily focusing on the older adult population, and identified relevant studies in PubMed, Google Scholar, and Embase databases. Additionally, we retrieved white papers and articles from popular media, when appropriate, to provide additional context. While we primarily focused on insomnia, we also included research on related sleep characteristics, such as total sleep time and sleep fragmentation, given the relevance of these variables to insomnia. This review adheres to the recommendations outlined in the SANRA guidelines for narrative reviews [21].

Trends in Insomnia prevalence in older adults

While nearly 50% of older adults report at least one symptom of insomnia [4], the rate of clinical insomnia diagnoses in this population remains low, with current estimates residing at 10%–20% [22–25]. The comparably lower prevalence of diagnosed insomnia may reflect limited awareness of clinicians regarding insomnia prevalence in later life and/or a shortage of sleep-focused healthcare providers [26]. Moreover, insomnia in older adults often co-occurs with conditions that are common in older people, such as depression [27], chronic pain (e.g. from arthritis), and other chronic health conditions [28], which can complicate diagnosis. Although recent diagnostic criteria for insomnia do not distinguish between “primary” insomnia and “secondary” insomnia—with the latter referring to insomnia symptoms that are largely attributable to another disorder—the lower diagnosis rate may be attributable to insomnia-type symptoms being addressed by managing comorbid conditions rather than directly targeting the insomnia [29]. On the other hand, we have limited data from studies that conducted rigorous insomnia screening and diagnosis that can help identify the true prevalence of later-life insomnia in the general population of older adults, against which we can compare the rates of clinical diagnosis. Given the evidence suggesting that untreated insomnia may increase the risk of developing health conditions, including arterial hypertension, psychiatric comorbidities, such as anxiety and depression, and obesity, accurate diagnosis and subsequent treatment could be key to the prevention of myriad poor health outcomes [25].

When discussing the prevalence of insomnia among older adults, it is important to remember that social disparities can affect both the prevalence and treatment of insomnia. Studies in community-based samples find that compared to white individuals, racially and ethnically minoritized older adults disproportionately experience symptoms of insomnia and sleep disturbances, such as short sleep duration and more frequent sleep disturbances [30, 31]. On the other hand, research also suggests that insomnia is more likely to be addressed clinically in white vs. racially minoritized individuals. For example, Holler et al. recently found that among almost N = 10 000 newly diagnosed insomnia patients, 13.5% of white patients received a sleep medication, whereas this was seen in only 6.2% of black patients [32]. These discrepancies likely reflect disparities in healthcare access and utilization [26]. The pattern of higher symptom burden but lower rates of treatment among racial and ethnic minorities is particularly concerning in light of the negative outcomes associated with untreated insomnia, as discussed below.

The reported prevalence of insomnia symptoms and disorder has risen dramatically over the past few decades. Population-based studies suggest that the prevalence of “difficulty sleeping” in both older [33] and younger [34] participants has increased over time. Data from the National Health and Nutrition Examination Survey show the percentage of participants reporting trouble sleeping to a healthcare provider among older adults (>65 years) increased from 27.0% in 2005 to 36.4% in 2018 (~35% relative increase) [33]. These trends are mirrored by Medicare data showing that insomnia diagnoses increased from 3.9% in 2006 to 6.2% in 2013, and insomnia medication use rose from 21.0% to 29.6% across those years among older adults [35]. More research is needed to understand the factors driving these trends. For example, public interest in sleep health may have been driven by the availability and popularity of sleep training apps [36] and wearable sleep trackers [37]. Moreover, initiatives such as Insomnia Awareness Day [38], led by the American Academy of Sleep Medicine, and the rise of workplace interventions aimed at improving sleep among employees [39], also reflect this growing appreciation for sleep’s role in health and well-being.

In addition to historical trends, it is important to observe within-person changes in insomnia. A recent longitudinal study examining transitions in sleep health phenotypes in a national sample of adults (M_age = 55 and 63, SD_age = 12 and 11, at times 1 and 2, respectively) [40] showed that the insomnia sleeper phenotype—characterized by four co-occurring self-reported sleep problems aligned with clinical symptoms of insomnia (short sleep duration, high daytime tiredness, frequent insomnia symptoms, and taking a long time to fall asleep)—is largely stable, with 92% of these individuals remaining in the same phenotype approximately 10 years later. This suggests that individuals with insomnia symptoms are unlikely to experience notable improvements in their sleep over time. In that study, participants with higher education were less likely to belong to the insomnia sleeper group, underscoring the sociodemographic correlates of insomnia and the need to address the condition in socially disadvantaged populations. While the aforementioned study was primarily in middle-aged adults, more research on longitudinal change in sleep among older adults is needed.

Recent findings in Insomnia-associated health outcomes

In recent years, our understanding of the relationship between sleep disturbances and later-life health outcomes has deepened. It is now clear that multiple aspects of sleep, including both objectively and subjectively measured insomnia symptoms, insomnia disorder, sleep duration, sleep disordered-breathing, and alterations in sleep architecture, are linked to aging-related outcomes, including cardiovascular and brain health. While this review focuses primarily on insomnia disorder and its symptoms, when discussing health outcomes, it is also important to evaluate these findings within the broader context of what is known about changes in other aspects of sleep (e.g. slow-wave sleep) and prevalent disorders (e.g. sleep disordered breathing) that occur with age and may influence the report of insomnia symptoms. Thus, we discuss here the health outcomes associated with insomnia as well as other forms of sleep disturbance. We point this out so readers understand that some of the literature included examines aspects of sleep that are not strictly part of insomnia (e.g. short sleep duration) but are still closely related.

In recent years, there has been a growing appreciation of the impact of sleep on heart health. Informed by a long history of studies showing sleep quality, and in particular insomnia, is a precursor to cardiovascular disease (CVD) [41–44], in 2022, the American Heart Association (AHA) introduced Life’s Essential 8, which lists the key risk and protective factors for CVD [45]. This model expanded upon Life’s Simple 7 by adding short sleep duration—recognizing it as a significant risk factor for CVD on par with diet and exercise. While short sleep duration was the main addition, the AHA recently published a scientific statement arguing for consideration of a broader range of sleep characteristics (specifically those in the multidimensional sleep health model) [46]. The importance of sleep disturbance, and specifically insomnia, to cardiovascular health has received renewed attention. In a systematic review of 21 observational studies, Ali et al. found that risk for myocardial infarction and CVD mortality was nearly 50% greater in those with insomnia vs. those without [47]. A more recent meta-analysis of nine studies by Dean et al. found that insomnia was associated with 69% increased risk for myocardial infarction [48]. Indeed, incorporating sleep health into models of CVD risk has actually been shown to improve the prediction of CVD events. In a study using data from the Multi-Ethnic Study of Atherosclerosis cohort, Makarem et al. demonstrated that adding various sleep health measures, including sleep duration and sleep efficiency, to a score encompassing Life’s Simple 7 significantly enhanced the ability to predict CVD and events [49]. While the majority of these studies examined the impact of insomnia symptoms on heart health in early and middle adulthood, there is evidence—albeit limited—that similar, if not larger, associations are seen in older adults [50, 51]. Given the growing importance of insomnia to CVD risk, we encourage future research that expands our understanding of the mechanisms driving these relationships, specifically in older adults given their vulnerability to declining health.

Given the importance of sleep to cardiovascular health, it follows that sleep may affect factors downstream of cardiovascular disease, such as brain health. In 2024, the AHA released a scientific statement regarding links of disturbed sleep with brain health, cognitive impairment, and dementia, particularly in older adults [52]. It is well established that poor sleep is associated with cognitive difficulties (e.g. sustaining attention, impaired memory, etc.) [53–55], and epidemiologic data suggest an increased risk for dementia diagnosis associated with insomnia and its symptoms [56]. Notably, however, sleep duration in middle age may have stronger implications for dementia diagnosis than sleep duration later in life [57]. In the past decade, these findings have been bolstered by studies linking sleep to biomarkers of dementia—specifically spurred by a 2013 landmark study suggesting that sleep-induced glymphatic clearance mechanisms may help remove from the brain toxins associated with neurodegenerative diseases [58]. Studies in animal models demonstrate that sleep deprivation, specifically, increases Alzheimer’s disease pathology, including amyloid-beta deposition [59, 60] and tau protein accumulation [61]. These associations have also been observed in humans. For example, poorer self-reported sleep has been shown to be associated with increased amyloid deposition [62], and alterations in sleep architecture—particularly lower slow-wave activity—are linked with amyloid and tau pathology across a variety of groups, including those not yet showing signs of cognitive impairment, or those at the very early stages of dementia [63, 64]. Moreover, in a recent analysis of Framingham Heart Study data, Himali et al. showed that for each percentage point decrease in slow-wave sleep over time, the risk for dementia increased 27% nearly 17 years later [65]. Of note, a small randomized trial by Lucey et al. found suvorexant, a medication that blocks wakefulness to induce sleep (details below), modifies Alzheimer’s disease proteins in healthy adults, further supporting a causal role of sleep in Alzheimer’s disease pathophysiology [66].

Despite the literature supporting disturbed sleep as a risk factor for cognitive decline, dementia, and biomarkers of poor brain health, sleep has yet to be recognized as a major risk factor for dementia by the Lancet Commission on Dementia Prevention, Intervention, and Care. Similar to AHA’s Life’s Essential 8, the Lancet Commission has identified risk factors for dementia that may account for up to 40% of dementia cases worldwide [67]. However, it has yet to identify poor sleep health as a major risk factor. The Commission considered sleep—particularly short and long sleep duration—but raised concerns about the potential bidirectional relationship between sleep and dementia, and noted studies did not yet consistently characterize sleep quality and circadian rhythm disruption, which the Commission suggested may be more relevant than sleep duration alone [68]. The Commission’s decision is surprising, given evidence from meta-analyses and mechanistic investigations identifying several pathways by which sleep impacts Alzheimer's disease biomarkers [58–61]. We support further research to understand the mechanisms and potential mediators linking insomnia and its symptoms to dementia, particularly in longitudinal follow-up studies, as well as more intervention studies aimed at improving brain health associated with insomnia.

Diagnosis of Insomnia in older adults

Above, we discussed the criteria for insomnia disorder in the DSM. In 2023, the American Academy of Sleep Medicine released its updated International Classification of Sleep Disorders (ICSD)-3-TR [69]. In that volume, chronic insomnia disorder requires the patient or an informant to report difficulty initiating or maintaining sleep, early final awakenings, resistance to going to bed on an appropriate schedule, or difficulty sleeping without a parent or caregiver intervention (criterion A). There must also be one or more of nine listed consequence or impairment options related to the nighttime sleep difficulty (criterion B). The sleep–wake complaints cannot be explained purely due to inadequate sleep opportunity or circumstances (criterion C). The sleep disturbance and associated daytime symptoms must occur at least three times per week (criterion D); must persist for at least 3 months (criterion E); and must not be solely due to another current sleep, medical, or mental disorder or substance use (criterion F). The short-term insomnia disorder criteria differ mainly by not requiring the three-times-per-week frequency and by permitting symptom duration of <3 months. The single change in the recent ICSD-3-TR insomnia disorder criteria was that sleep disturbance and daytime symptoms were “not solely” due to another disorder, which is especially relevant for the older population. That is, these criteria recognize that even with comorbidities that might affect sleep, insomnia often evolves into “an independent, self-sustaining disorder” that warrants a separate diagnosis and management [69].

Despite these new criteria, the protocols for diagnosing insomnia have remained consistent over the years, and there are numerous factors that are important to consider when diagnosing the condition in older adults. For instance, there is importance placed on gathering detailed information on sleep characteristics and daytime symptoms [70] and, whenever possible, collecting collateral information from a bed partner or caregiver. This can be especially important for older adults with cognitive impairment. Because aging is often associated with the development of chronic conditions and increased medication use, other considerations should include medical conditions and treatments that can affect sleep (e.g. obesity, ferritin levels, all current medications and supplements). Use of substances such as nicotine, caffeine, alcohol, and cannabis should also be assessed. Beyond specific sleep–wake complaints, it is important to assess daytime and nighttime routines and the sleep environment.

Sleep diaries or logs, ideally maintained over several weeks, are helpful for diagnosis and treatment planning; examples include the Consensus Sleep Diary [71] and a downloadable sleep diary on the American Academy of Sleep Medicine (AASM) Sleep Education website (https://sleepeducation.org/docs/default-document-library/sleep-diary.pdf). To the extent that the patient is comfortable with mobile technology, many digital apps are available that include reminders to facilitate sleep diary completion. For example, the Department of Veteran Affairs previously developed a mobile app for veterans (CBT-I Coach), which includes a user-friendly sleep diary that can be used on a smartphone. The app was developed using evidence-based practice principles, specifically for the US veteran population, and its usability, effectiveness, and acceptability have been evaluated and deemed acceptable to this population [72]. Some older adults may have difficulty completing diaries due to impairments in memory or other cognitive domains. Input from family or caregivers can be particularly useful in these circumstances.

Although insomnia disorder diagnosis relies primarily on patient and collateral reports, objective measures, such as actigraphy, polysomnography, and in some cases, consumer wearables (e.g. Fitbit) can add valuable context and aid in the differential diagnosis, such as identifying sleep-related breathing or movement disorders and parasomnias (with polysomnography) and circadian rhythm sleep–wake disorders (actigraphy) [73–75]. While useful in all populations, objective assessments may be especially beneficial in the diagnosis of insomnia in older adults, as other sleep disorders may be contributing to these symptoms, particularly sleep-disordered breathing, which is prevalent in older adults. It should be noted that, despite its high sensitivity (i.e. ability to detect sleep), actigraphy may underestimate wake-after-sleep onset (WASO) and sleep fragmentation, which may be particularly pronounced in older adults and those with insomnia (i.e. it has low specificity) [76].

With technological advances in consumer- and research-grade monitoring devices, such as wearable, nearable, and contactless monitoring, and home-use EEG headband devices, our ability to identify specific subtypes of insomnia has improved [77]. Of note, a recent white paper published in SLEEP reviewed the use of consumer wearables for assessing sleep and diagnosing sleep disorders. The authors ultimately recommended that more research is needed to evaluate these consumer-grade devices, primarily because they do not provide raw data to the end user but instead yield summaries produced by proprietary algorithms [37]. The authors called for more validation studies of these devices in older adults, especially because most such studies were in younger samples [37]. Furthermore, new analytical approaches (machine learning and artificial intelligence, large-scale data mining) have helped facilitate diagnosis in patients [78]. This may be especially important for older adults, who may benefit greatly from personalized approaches due to the heterogeneous factors that may contribute to insomnia symptoms in later life.

Multiple factors drive the under-recognition and undertreatment of insomnia disorder in older adults. As discussed above, clinicians may not adequately assess or directly treat insomnia because they view it as a consequence of a comorbid condition. In addition, patients, families, and healthcare providers may attribute sleep changes to normal aging, viewing them as inevitable rather than as treatable health concerns. Patients may not perceive sleep issues as problematic or may worry about stigma, especially if they view their sleep-related symptoms as related to mental health problems. Numerous organizations work to raise awareness about the importance of insomnia and general sleep health for older adults, including among providers. These include public health agencies (e.g. Centers for Disease Control, World Health Organization), professional medical societies (e.g., AASM, American Geriatrics Society, Gerontological Society of America), non-profit health organizations (e.g. National Sleep Foundation), patient advocacy groups, primary care networks, educational institutions, research societies (e.g. Sleep Research Society), and workplace wellness programs. In clinical settings, the identification of insomnia and other sleep disorders in older adults will improve as specific sleep-related items are incorporated into standard patient history forms and routine review of systems assessments, and as electronic medical record systems facilitate screening for sleep-related symptoms.

Treatment of insomnia in older adults

Broadly speaking, cognitive and behavioral treatments are considered first-line interventions for chronic insomnia. Clinical practice guidelines from the American College of Physicians [79], AASM [80], Veterans Affairs/Department of Defense [81], European Sleep Research Society [82], and other leading organizations confirm that relative to the benefits of insomnia pharmacotherapy, the benefits of cognitive–behavioral treatment for insomnia (CBT-I) are comparable in the short term, with gains better maintained over time. Relative to insomnia pharmacotherapy, CBT-I is less likely to incur next-day sedation and typically presents a more favorable risk/benefit profile, especially among older adults, for whom insomnia pharmacotherapy should be used with caution [83]. Further, given the prevalence of medical and psychiatric comorbidities increases with age, it is notable that CBT-I is effective in insomnia comorbid with a broad range of conditions, including chronic pain [84] and depression [85]. Moreover, from a patient-centered perspective, older adults with insomnia prefer non-drug treatment approaches when available [86].

Although a detailed discussion is beyond the scope of this review, individual CBT-I treatment components include sleep hygiene education, stimulus control [87], restriction of time in bed [88], relaxation, and cognitive restructuring, to name several. CBT-I is highly amenable to personalization, and modifications are often required when working with older adults. For example, Reidel developed sleep compression, a more gradual approach to restriction of time in bed that is preferred by older adults [89, 90]. Similarly, cognitive deficits experienced by some older adults can reduce the effectiveness of traditional cognitive therapy approaches or, worse, cause frustration and treatment discontinuation. To overcome this limitation, investigators have examined the behavioral components of CBT-I among older adults. For example, a 2022 meta-analysis of 15 studies of older adults (total N = 498) by McLaren and colleagues found that while restriction of time in bed, stimulus control, and multicomponent behavioral treatments all improved one or more measures of subjective sleep, multicomponent interventions demonstrated the largest effect sizes [91]. Similarly, in a 2023 meta-analysis of four studies of older adults (total N = 190), Chen and colleagues reported that brief behavioral therapy for insomnia (BBTI) significantly improved subjective sleep [92]. Beyond these recent and welcome contributions to the literature, it is important to recognize the substantial historical evidence base pertaining to behavioral insomnia care among older adults, including seminal studies and even a focused textbook published over two decades ago [90, 93, 94].

Given the strength of evidence for CBT-I coupled with the gross shortage of trained behavioral insomnia care providers, it is vital to increase access to evidence-based insomnia care for older adults [95]. Two areas of scientific inquiry have been training non-expert providers and leveraging technology. Nearly 20 years ago, Espie and colleagues utilized primary care nurses to deliver CBT-I in a group format, with positive results [96]. Similarly, the original BBTI trial utilized non-expert master’s-level clinicians to deliver care specifically to older adults [97], and more recent efforts have utilized non-clinician sleep coaches, supervised by a licensed psychologist, to deliver CBT-I to older adult veterans [98, 99].

Investigators have also focused on self-help approaches, including those that leverage technology, to disseminate behavioral insomnia care among older adults. Methods include bibliotherapy [100], mobile applications [101], and telehealth [85, 102]. In recent years, the development of digital therapeutics for insomnia has become available to patients, including for older adults [72, 103, 104]. These technologies provide CBT-I over the internet, expanding access to these proven behavioral therapies. For example, programs like Sleepio [105], CBT-I Coach [106], and Somryst [107] provide accessible and flexible solutions for the delivery of CBT-I. Numerous meta-analyses indicate that these therapies are effective and well received by patients. Although attrition remains a challenge, results can be on par with in-person CBT-I [108–110]. Many older adults still encounter barriers to attending traditional insomnia therapy in person, stemming from mobility limitations and transportation challenges and lack of sleep clinics in the community; thus, digital CBT-I has great potential to expand access to treatment [111]. Personalized treatment plans that relate to health and environmental factors of older adults can improve adherence and outcomes. However, further research is necessary to evaluate how these tailored plans specifically benefit this demographic.

Despite the effectiveness of CBT-I and other treatment modalities, pharmacotherapies remain the most common insomnia treatment. Historically, the most commonly used pharmacological treatments have included benzodiazepines (BZDs) and non-BZD hypnotics (colloquially known as the z-drugs: zolpidem, zaleplon, and eszopiclone). There are concerns about the prevalent use of these agents, particularly in older adults, which, until the mid-2010s, saw rising rates in both prescribing and use among older people [35, 112–116] These agents have been listed on the Beers Criteria, a list of medications published by the American Geriatrics Society that are considered to be potentially inappropriate when used in older adults—the primary concerns being risk for falls/hip fractures, cognitive decline, and dependence/withdrawal [117].

Since the mid-2010s, however, there have been significant advances in the pharmacological treatment of insomnia. Newer therapies have been developed, including orexin receptor antagonists (ORAs) [118]. ORAs create sedative effects by blocking orexin receptors to reduce wakefulness, rather than binding to gamma-aminobutyric acid (GABA) receptors like agents from other classes of sedative–hypnotic medications [119]. Prescribing patterns of ORAs in the United States remain unclear, and more research is urgently needed to assess these trends, especially in older adults, given the growing market share of these products [120]. While less is known about prescribing in the United States, a 2023 study analyzing Japan’s national healthcare data reported that 20.2% of new hypnotic users were prescribed an ORA, emphasizing its increasing role in insomnia treatment [121].

At the same time, off-label prescribing of medications for insomnia has increased in recent years. For example, there has been an increasing trend in the use of low-dose trazodone, an antidepressant that has sedative effects. Wong et al., using data from the IBM MarketScan database, found that use of this agent among those with insomnia increased from 8.7% in 2011 to 14.5% in 2018 [122]. Furthermore, there is evidence that the use of melatonin supplements has also increased, with a recent study using data from National Health and Nutrition Examination Survey showing that melatonin use in the United States increased from 0.4% in 1999/2000 to 2.1% in 2017/2018, a nearly fivefold increase [123]. While there have been increases in the off-label use of medications and supplements in the general population—including, but not limited to, older adults—these changing patterns have emerged despite limited data on their efficacy for insomnia or long-term safety. As an example, melatonin may not be an appropriate insomnia treatment, especially because it is a chronobiotic that primarily affects sleep timing [124].

With advancements in new pharmacological approaches and therapeutic options, along with potential increases in access to behavioral therapies through digital therapeutics [36, 125, 126], recent evidence suggests a decline in medication use for sleep disorders. We recently found that the use of medications specifically for sleep disturbance decreased by just over 31% between 2013 and 2018, primarily driven by declines in the use of medications that were Food and Drug Administration-approved for insomnia (vs. those used for insomnia off-label), particularly among those in the oldest age groups [127]. Specifically, the use of FDA-approved sleep medications declined by 86% for those aged ≥80 years. As treatment options for insomnia evolve, more research is needed to identify the best approaches for effective treatment, particularly in older adults.

Conclusions

In this narrative review, we discussed the latest research and clinical trends in insomnia in older adults. Figure 1 presents several of these developments over the past 10 years. We examined trends in the prevalence of insomnia symptoms and disorder and presented some of the growing evidence linking insomnia to key health outcomes, including CVD and dementia. We identified challenges in diagnosing the condition and described the newest treatments available. While we aimed to provide a broad overview of insomnia in older adults through our narrative review, it is important to note that narrative reviews are not systematic, and there is a need for additional comprehensive synthesis, including umbrella reviews. Therefore, we encourage future systematic reviews, meta-analyses, or other review types that could identify further gaps in the literature and incorporate new technologies using methods that are less subject to author bias.

Figure 1.

Key milestones in the evolving understanding and management of insomnia in older adults. Notes: AASM = American Academy of Sleep Medicine; ACP = American College of Physicians; AHA = American Heart Association; CBT-I = cognitive behavioral therapy for insomnia; ISCD-3-TR = International Classification of Sleep Disorders, Third Edition, Text Revision; ORA = orexin receptor antagonist; VA = Veterans Affairs.

Overall, our review emphasizes that insomnia in older adults remains a public health issue, necessitating further research to address an unmet need for diagnosis and care. Moreover, we highlight that, despite expanded availability of behavioral therapies, digital therapeutics (e.g. online CBT-I), and newer medications such as the ORAs, insomnia continues to be a significant health condition affecting older people, indicating that current efforts to facilitate insomnia diagnosis and allocate treatment need to be sustained. As the population ages, we can expect to see an increasing number of older adults who require insomnia care. We are entering a new era in the management of insomnia in older adults, and, with the introduction of new pharmacologic agents and digital access to behavioral treatments for insomnia, there is a promising opportunity to address this growing public health need.

Funding

This study was supported in part by the National Institute of Health (R01AG079391, K01AG061239, P30AG028740, R56AG065251, R01HL163226, R01AG080613, R21AG078917).

Disclosure statement

Financial disclosure: C.N.K. has served as a consultant to Jazz Pharmaceuticals. E.M.W.’s institution has received research funding from the AASM Foundation, Department of Defense, Merck, NIH/NIA, ResMed, the ResMed Foundation, and the SRS Foundation. E.M.W. has served as a scientific consultant to Axsome Therapeutics, DayZz, Eisai, EnsoData, Idorsia, Merck, Nox Health, Primasun, Purdue, and ResMed and is an equity shareholder in WellTap. A.P.S. is supported in part by grants from the National Institutes of Health/National Institute on Aging. He has served as a consultant to Sequoia Neurovitality, BellSant, Inc., and Amissa, Inc. D.N.N. has served as a consultant to Eisai, Idorsia, and Johnson & Johnson. All other authors report no relevant financial conflicts of interest.

Non-financial disclosure: None.

Data availability

The data underlying this article are available in the article.