Recent Developments in the Management of Insomnia in Later Life
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Purpose of review
Insomnia impacts a significant proportion of older adults yet is not an inevitable consequence of aging and is amenable to intervention. The aim of this narrative review is to provide an overview of recent recommendations and empirical findings regarding the management of insomnia in older adults.
The treatment of insomnia with cognitive behavioral therapy for insomnia (CBT-I) continues to be empirically supported and the recommended first-line intervention for adults. Accumulating evidence indicates that other non-pharmacological therapies for insomnia, such as mindfulness-based therapies, light therapy, and physical activity interventions, as well as treatment delivered by non-clinician “sleep coaches” also positively impact insomnia symptoms. Finally, recent systematic reviews offer guidelines and recommendations for pharmacological management of insomnia.
CBT-I remains the recommended first-line treatment for insomnia across adult ages. There is a continued need to increase the availability and optimize the delivery of CBT-I and other therapies for older adults with insomnia to maximize treatment benefits. There is also evidence for some benefit of pharmacological agents to treat insomnia; however, these are not without risks, particularly in the geriatric population.
KeywordsInsomnia Sleep Aging Older adults Therapy Treatment
American College of Physicians
American Academy of Sleep Medicine
Brief behavioral treatment for insomnia
Cognitive behavioral therapy for insomnia
Insomnia Severity Index 
Mindfulness-based stress reduction
Mindfulness-based therapy for insomnia
Pittsburgh Sleep Quality Index 
Randomized controlled trial
Sleep disordered breathing
Sleep onset latency
Total sleep time
Total wake time
Wake after sleep onset
Dr. Tighe is supported by the Advanced Fellowship Program in Mental Illness Research and Treatment, VISN 4 MIRECC (Director: D. Oslin; Pittsburgh Site Director: G. Haas), VA Pittsburgh Healthcare System. Dr. Bramoweth is supported by Career Development Award 13-260 from the Department of Veterans Affairs, Health Services Research and Development Service. The contents of this paper do not represent the views of the Department of Veterans Affairs or the United States Government.
Compliance with ethical standards
Conflict of interest
Adam D. Bramoweth reports grants from the US Department of Veterans Affairs, Health Services Research and Development Service, during the conduct of the study.
Caitlan A. Tighe declares that she has no conflict of interest.
Human and animal rights and informed consent
This article does not contain any studies with human or animal subjects performed by any of the authors.
References and Recommended Reading
Recently published papers of particular interest have been highlighted as: •• Of major importance
- 1.American Psychiatric Association., American Psychiatric Association. DSM-5 Task Force. Diagnostic and statistical manual of mental disorders: DSM-5. Arlington, VA: American Psychiatric Association; 2013.Google Scholar
- 4.•• Qaseem A, Kansagara D, Forciea M, Cooke M, Denberg TD, for the Clinical Guidelines Committee of the American College of P. Management of chronic insomnia disorder in adults: a clinical practice guideline from the american college of physicians. Ann Intern Med. 2016;165(2):125–33. This publication provides clinicians with guidelines for managing chronic insomnia disorder in adults, based on comprehensive reviews of randomized controlled trials published between 2004 and 2015.CrossRefPubMedGoogle Scholar
- 14.Perlis ML, Aloia M, Kuhn BR. Behavioral treatments for sleep disorders: a comprehensive primer of behavioral sleep medicine interventionsAmsterdam ; Boston: Academic,; 2011.Google Scholar
- 17.•• Brasure M, Fuchs E, Mac Donald R, Nelson VA, Koffel E, Olson CM, et al. Psychological and behavioral interventions for managing insomnia disorder: an evidence report for a clinical practice guideline by the American College of Physicians. Ann Intern Med. 2016;165(2):113–124. This report provides a comprehensive review of psychological or behavioral RCTs for insomnia disorder published from 2004 to 2015. Findings from this review informed the 2016 clinical practice guidelines published by the American College of Physicians.Google Scholar
- 19.Kabat-Zinn J. Mindfulness meditation: what it is, what it isn’t, and it’s role in health care and medicine. In: Haruki Y, Ishii Y, Suzuki M, editors. Comparative and psychological study on meditation. Eburon, Netherlands: Eburon Publishers; 1996. p. 161–9.Google Scholar
- 26.•• Sateia MJ, Buysse DJ, Krystal AD, Neubauer DN, Heald JL. Clinical practice guideline for the pharmacologic treatment of chronic insomnia in adults: an American Academy of Sleep Medicine Clinical Practice Guideline. J Clin Sleep Med. 2017;13(2):307–49. This report is based on a comprehensive review of RCTs of pharmacologic treatment options for insomnia disorder published through January 2016. Treatment recommendations are outlined with reports of the strength of evidence supporting each recommendation.CrossRefPubMedPubMedCentralGoogle Scholar
- 27.•• American Geriatrics Society 2015 Beers Criteria Update Expert Panel. American Geriatrics Society 2015. Updated Beers Criteria for potentially inappropriate medication use in older adults. J Am Geriatr Soc. 2015;63(11):2227–46. This publication provides guidelines regarding the safe prescription of medications to older adults.CrossRefGoogle Scholar
- 28.Micromedex® 1.0 (Healthcare Series), (electronic version). Truven Health Analytics, Greenwood Village, Colorado, USA. Available at: http://www.micromedexsolutions.com.pitt.idm.oclc.org/.
- 29.Center for Drug Evaluation and Research (U.S.). Drugs@FDA. Washington D.C.: U.S. Food and Drug Administration, Center for Drug and Evaluation Research. Available from: http://www.accessdata.fda.gov/scripts/cder/drugsatfda/Available from: http://purl.access.gpo.gov/GPO/LPS60696.
- 32.Alam A, Voronovich Z, Carley JA. A review of therapeutic uses of mirtazapine in psychiatric and medical conditions. Prim Care Companion CNS Disord. 2013;15(5).Google Scholar
- 33.Trazodone: drug information. Waltham, MA.: UpToDate; 2018.Google Scholar
- 34.Teton Data Systems (Firm). STAT!Ref. Jackson, Wyo.: Teton Data Systems; 2000.Google Scholar
- 36.Montgomery P, Dennis J. Physical exercise for sleep problems in adults aged 60+. Cochrane Database Syst Rev 2002(4):CD003404.Google Scholar
- 46.Montgomery P, Dennis J. Bright light therapy for sleep problems in adults aged 60+. Cochrane Database Syst Rev 2002(2):CD003403.Google Scholar
- 47.Jespersen KV, Koenig J, Jennum P, Vuust P. Music for insomnia in adults. Cochrane Database Syst Rev 2015(8):CD010459.Google Scholar
- 50.Fung CH, Vitiello MV, Alessi CA, Kuchel GA, Faculty ANSCPCa. Report and research agenda of the American Geriatrics Society and National Institute on Aging bedside-to-bench conference on sleep, circadian rhythms, and aging: new avenues for improving brain health, physical health, and functioning. J Am Geriatr Soc 2016;64(12):e238-ee47.Google Scholar
- 56.Martin JL, Song Y, Hughes J, Jouldjian S, Dzierzewski JM, Fung CH, et al. A four-session sleep intervention program improves sleep for older adult day health care participants: results of a randomized controlled trial. Sleep. 2017;40(8).Google Scholar
- 61.Chan WS, Williams J, Dautovich ND, McNamara JPH, Stripling A, Dzierzewski JM, et al. Night-to-night sleep variability in older adults with chronic insomnia: mediators and moderators in a randomized controlled trial of brief behavioral therapy (BBT-I). J Clin Sleep Med. 2017;13(11):1243–54.CrossRefPubMedGoogle Scholar