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Maturitas. 2013 November ; 76(3): . doi:10.1016/j.maturitas.2013.05.007.

Optimizing Sleep in Older Adults: Treating Insomnia

Alexandra M. Wennberg, B.A.1, Sarah L. Canham, Ph.D.1, Michael T. Smith, Ph.D.2, and
Adam P. Spira, Ph.D.1
1Department of Mental Health, Johns Hopkins Bloomberg School of Public Health

2Department of Psychiatry and Behavioral Sciences, Johns Hopkins School of Medicine

Abstract
As the world’s population ages, the elevated prevalence of insomnia in older adults is a growing
concern. Insomnia is characterized by difficulty falling or remaining asleep, or by non-restorative
sleep, and resultant daytime dysfunction. In addition to being at elevated risk for primary
insomnia, older adults are at greater risk for comorbid insomnia, which results from, or occurs in
conjunction with another medical or psychiatric condition. In this review, we discuss normal
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changes in sleep that accompany aging, circadian rhythm changes and other factors that can
contribute to late-life insomnia, useful tools for the assessment of insomnia and related problems
in older people, and both non-pharmacological and pharmacological strategies for the
management of insomnia and optimization of sleep in later life.

Keywords
aging; primary insomnia; comorbid insomnia; treatment

1.1. Introduction
The world’s population of older adults is growing. In the past 50 years, the number of older
adults has tripled, and it will triple again by 2050 [1]. Sleep complaints are prevalent among
older adults, with over 50% reporting difficulty initiating or maintaining sleep [2]. Findings
suggest that sleep complaints in older adults are due to multiple factors, including changes in
circadian rhythms [3], an age-related increase in the prevalence of chronic medical
conditions [4, 5], and psychosocial changes that commonly accompany aging [6, 7]. In
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addition to having an elevated prevalence of sleep complaints, older adults are more likely to
have clinical levels of these complaints, and to receive a diagnosis of insomnia [8]. As the
population of older adults continues to grow, so too will the prevalence of insomnia and
associated conditions, making assessment and treatment increasingly important. Here, we
briefly review normal age-related changes in sleep, primary and comorbid insomnia, tools
for the assessment of insomnia and related problems, and pharmacological and non-
pharmacological treatments for optimizing sleep in later life.

© 2013 Elsevier Ireland Ltd. All rights reserved.

Corresponding author: Adam P. Spira, Ph.D., 624 N. Broadway, Room 794, Baltimore, Maryland 21205, USA, Tel: (001)
410-614-9498, Fax: (001) 410-614-7469, [email protected].
Publisher's Disclaimer: This is a PDF file of an unedited manuscript that has been accepted for publication. As a service to our
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 Wennberg et al. Page 2

Age-Related Changes in Sleep and Circadian Rhythms

Sleep is currently classified into four stages, which are differentiated by their waveforms on
the electroencephalogram (EEG) and by other physiological signals. The first three stages
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are non-rapid eye movement (NREM) 1, 2, and 3, and the fourth stage is rapid eye
movement (REM) sleep [9]. NREM 1 is the lightest stage, and accounts for 18% of older
adults’ sleep time [10]. Sleep deepens in NREM 2, which accounts for 48% of sleep time,
and deepens further in NREM 3, which accounts for 16% of an older individual’s sleep time
and is referred to as slow-wave sleep (SWS), due to its slow (0.05–2 HZ), high-amplitude
EEG signal [10]. Finally, REM sleep is referred to as “paradoxical sleep” because brain
wave activity is similar to that of a waking brain, but the body is paralyzed [11]. Most
dreaming occurs during REM sleep, which accounts for 18% of sleep time among older
adults [10]. Beginning in middle age, adults spend less time in SWS and REM sleep and
exhibit decreases in total sleep time, but sleep efficiency (the proportion of time in bed spent
sleeping) continues to decrease past age 60 [12].

In addition to changes in sleep, older adults commonly demonstrate changes in circadian

rhythms, the physiological and behavioral processes that oscillate once approximately every
24 hours and are controlled by the suprachiasmatic nucleus (SCN) in the hypothalamus [13].
The sleep-wake cycle is one of these rhythms. The SCN responds to external cues, known as
zeitgebers, such as light, which are central to synchronizing circadian rhythms to the
environment [14]. Several physiological age-related changes are thought to produce
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alterations in circadian rhythms. For example, older adults exhibit decreases in the number
and density of melatonin-, vasoactive intestinal polypeptide-, and vasopressin-expressing
neurons in the SCN that may interfere with its normal function [13]. Deterioration of the
SCN is believed to result in a reduction in the amplitude of core body temperature, a marker
of circadian rhythms [15, 16]. In addition, it is common for older adults to go to bed and
wake up at earlier times than younger people. This shift is known as a circadian phase
advance, and may result from the physiological changes just described and from additional
factors [3].

2.1. Insomnia: Definition and Contributing Factors

While over half of older adults report at least one sleep complaint, a smaller percentage of
older adults meet clinical criteria for diagnosis of insomnia [2, 8]. Insomnia can be separated
into two types: “primary” and “secondary” or “comorbid.” As of 2005, however, the
National Institute of Health (NIH) recommended that the term “comorbid insomnia” replace
“secondary insomnia” to reflect the clinical challenge in defining whether insomnia is a
symptom of a primary disorder, or a separate, comorbid disorder [8]. Insomnia that initially
occurs secondary to a physical or psychiatric disorder may evolve into an independent
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problem that has a bidirectional relationship with the original primary disorder [17]. As
insomnia symptoms persist, the likelihood that cognitive and behavioral adaptations play an
increasing role in the perpetuations of symptoms is enhanced. Primary insomnia is
characterized by trouble initiating or maintaining sleep, or by non-restful sleep that causes
impaired daytime functioning, and is not attributable to a general medical condition,
medication, another sleep disorder, or a mental disorder [18]. While the etiology of primary
insomnia remains unclear, both physiological and psychological theories have been
proposed, including: hyperarousal, heightened physiological stress responses, predisposing
personality characteristics, attitudes towards and misconceptions about sleep, and
maladaptive compensatory behaviors (e.g., extending time in bed) [8].

Comorbid insomnia is similar in clinical presentation to primary insomnia but results from
primary sleep disorders, medical conditions, psychiatric disturbances, medication use, and
psychosocial factors associated with aging (e.g., retirement, inactivity, or caregiving) [6, 7,

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19]. Compared to younger people, older adults have higher rates of primary sleep disorders
other than insomnia, such as obstructive sleep apnea (OSA), restless legs syndrome (RLS),
and periodic limb movements (PLMs), which are risk factors for insomnia symptoms [20].
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OSA affects 19% to 57% of older adults and is characterized by repeated cessation or
attenuation of breathing (“apneas” and “hypopneas”, respectively) during sleep [21]. The
most common OSA symptoms are loud snoring or gasping during sleep and daytime
sleepiness [22]. RLS is characterized by uncomfortable sensations in the legs, marked by the
urge move one’s legs, which are relieved by movement of the legs; these symptoms have a
distinct circadian pattern (minimal in the morning and worse at night) making it difficult to
sleep [20]. PLMs are involuntary limb jerks experienced by up to 45% of older adults, are
frequently observed among individuals with RLS, and can disrupt the sleep of both affected
individuals and their bed partners [23].

The bulk of insomnia symptoms in older adults may be attributable to the increased
prevalence of chronic conditions in this population; only 1% to 7% of insomnia in later life
occurs independently of chronic conditions [4, 5]. A study of older adults found that
approximately 25% of respondents had four or more chronic conditions, and two-thirds of
these reported sleep problems [5]. Chronic pain is frequently accompanied by insomnia in
older adults [5]. Pain and sleep are interrelated; pain has been shown to disrupt sleep, but
sleep deprivation can also result in a decreased pain threshold [24]. Osteoarthritis (OA) is
often a source of pain in older adults, affecting more than 50% of those aged 65 and older
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[25]. The chronic course of OA is associated with chronic comorbid insomnia in older adults
[26].

Chronic insomnia is also prevalent in older adults with mood disorders, and insomnia is
among the diagnostic criteria for several psychiatric disorders [18]. Insomnia is particularly
associated with depression and generalized anxiety disorder (GAD); between 40% and 60%
of insomnia patients have depressive or GAD symptomatology [27]. Though insomnia can
be a symptom of these disorders, it can also contribute to or exacerbate psychiatric
disorders, and should be targeted for treatment when present [17].

Lifestyle changes common in old age, such as retirement, reduced mobility, and reduced
social interaction are additional sources of sleep disruption [28–30]. Structured daily
activities, such as work and scheduled social interactions, are thought to serve as zeitgebers
[28]. It is common for older adults to become a caregiver for a family member with
functional impairment—often a spouse. Caregivers, particularly those caring for a family
member with dementia, have sleep patterns similar to individuals with depression or
insomnia [31]. Sleep problems are more prevalent in women who are caregivers, and those
experiencing greater caregiving-related distress, suggesting that caregiving may cause
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ruminations and anxiety while lying in bed [7, 32]. Among family caregivers of older adults
with dementia, disturbed care recipient sleep and related nocturnal behavior problems are
burdensome and commonly cited as the reason for nursing home placement [33, 34].
Recently, greater objectively measured sleep disturbance among a general population
sample of older women was linked to a greater risk of functional decline and placement in a
nursing or personal care home [35, 36], but the mechanisms underlying this association
remain unclear.

Circadian phase advance in older adults can lead to less total time in bed, greater daytime
sleepiness, and more daytime napping, which can further contribute to complaints about
nighttime sleep [14, 15]. It has been hypothesized that age-related changes may occur
downstream from the SCN (e.g., the age-related decline of behavioral and physiological
rhythms may result in less effective periodic signals that are important for maintaining
oscillation in peripheral tissues), and that, due to these downstream changes, circadian

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 Wennberg et al. Page 4

signals are no longer transmitted with the same strength to the pacemaker [37, 38]. This
results in a disrupted feedback loop, and leads to sleep complaints, and daytime sleepiness
and napping [37, 38]. Further, age-related yellowing of the eye’s lens may restrict light input
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to the SCN, and reductions in input from this signal can disrupt the sleep-wake cycle [39].

3.1. Assessment of Insomnia in Older Adults

Various self-report measures can be used to assess insomnia, including sleep diaries and
questionnaires. To complete a sleep diary, the patient records their sleep patterns (e.g., times
into and out of bed, number and length of nighttime awakenings), usually over a week or
two, and the results are reviewed by a clinician [40]. Although there is no standard format
for sleep diaries, an effort has been made to standardize them. In 2005 a group of insomnia
experts developed a Consensus Sleep Diary that included items for sleep onset latency, wake
after sleep onset, total sleep time, time in bed, sleep efficiency, and sleep satisfaction [40].
Although polysomnography is generally not indicated to assess insomnia, because older
adults have higher rates of sleep disorders other than insomnia, clinician should carefully
screen for signs and symptom of other sleep disorders and have a low threshold for referring
older adults for a sleep study, especially if they do not adequately respond to treatment.

While sleep diaries are extremely useful for assessing sleep patterns and insomnia and are a
core component of behavioral therapies for insomnia, they require that a patient take them
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home, complete them over a series of nights, and return them to a clinician with insomnia
expertise for interpretation [40, 41]. There are several questionnaires, however, that are
useful for rapid assessment of insomnia symptoms and related problems and can be
completed during an office visit. Two of these are the Pittsburgh Sleep Quality Index (PSQI)
and the Insomnia Severity Index (ISI). The PSQI is a 19-item questionnaire that measures
seven domains of the respondent’s sleep over the prior month (i.e., sleep quality, sleep
latency, sleep duration, sleep efficiency, sleep disturbances, use of sleep medication,
daytime dysfunction) and yields a global score, with higher scores indicating greater sleep
disruption [42]. Global scores >5 are generally considered to be indicative of a clinically
significant sleep disturbance [42], but it is unclear whether this cutoff is appropriate for
older adults. A study in older men found that the PSQI has good internal consistency and
validity; measures of internal consistency were improved when the items pertaining to
daytime functioning and medication use were removed [43] and a study in older women
came to many of the same conclusions [44].

While the PSQI is a useful tool for general assessment of sleep-related problems in older
adults, the ISI was developed to specifically focus on the diagnostic criteria for insomnia in
both the DSM-IV and ICSD [41, 18, 19]. The 7-item ISI measures the subjective symptoms
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and negative outcomes of insomnia over the past two weeks, and the worries and distress
caused by these [41]. A score >7 on the ISI indicates “subthreshold” levels of insomnia;
scores >14 indicate “clinical insomnia” [41]. Compared to sleep diaries, the ISI has good
validity and high internal consistency middle-aged and older age insomnia patients, and has
been shown to be sensitive to detect changes over time [41].

4.1. Interventions for Insomnia in Older Adults

Interventions for insomnia include behavioral and cognitive-behavioral therapy (CBT),
lifestyle interventions, and pharmacotherapy; however the evidence supporting the
effectiveness of these individual interventions varies [8, 26, 30, 32, 45, 46]. Behavioral
therapies include sleep restriction and stimulus control interventions, as well as sleep
hygiene and relaxation [47]. Sleep restriction involves reducing time in bed to the time an
individual is actually able to sleep until sleep efficiency improves [48]. Next, time in bed is
gradually increased until the patient is able to fill the desired time in bed with consolidated

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sleep [48]. Alternatively, sleep compression involves gradual reductions in time spent in bed
to the amount of time an individual is actually asleep, as compared to an immediate shift
[49]. Stimulus control interventions aim to reassociate the bed and bedtime with sleep, and
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to reduce the arousal and frustration related to lying in bed unable to sleep. Stimulus control
techniques include going to bed only when tired; using the bed only for sleep and sex;
leaving the bed if unable to fall asleep within 15 to 20 minutes; and waking at a consistent
time every morning [50]. Sleep hygiene education provides information on how exercise,
diet, substances (caffeine, medications, alcohol, nicotine), and the environment (light, noise,
heat) can affect sleep [51, 52], while relaxation training attempts to calm physiological
arousal by instructing individuals to sequentially tense and relax muscles or instructs
individuals to engage in guided imagery, diaphragmatic breathing, or meditation [32, 53,
54]. Cognitive therapy attempts to restructure negative or erroneous thoughts, ideas, and
attitudes about sleep, and in older adults this involves educating persons about normal age-
related changes in sleep vs. abnormal sleep in later life [51, 8].

When sleep hygiene education, stimulus control, sleep restriction, or relaxation training are
used in various combinations, the intervention is known as multicomponent CBT; there is
good evidence for the effectiveness of multicomponent CBT in improving insomnia
symptoms in older adults as well as for sleep restriction/compression as a stand-alone
treatment [32, 47, 55, 56, 57]. There is less evidence that sleep hygiene education, relaxation
training or cognitive therapy improves insomnia symptoms in older adults when these are
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used as stand-alone therapies [32, 57]. CBT interventions are generally brief (e.g., one
weekly session for four to eight weeks), but the effects, as compared to pharmacotherapy,
are long-term [58, 52]. In a randomized control trial with adults experiencing chronic
insomnia, there were short-term (3-months post–intervention) improvements in sleep
efficiency and time awake after sleep onset for all three experimental groups (those
receiving temazepam; those receiving CBT [including behavioral, cognitive, and educational
components]; and those receiving both temazepam and CBT) compared to the placebo group
as measured by sleep diaries and polysomnography, though, only the CBT-only group
sustained these improvements at 24-months post–intervention [52]. Studies comparing CBT
interventions to hypnotics have also found long-term improvements in total sleep time, total
wake time, SWS, subjective sleep quality, and levels of distress, as compared to hypnotics,
which showed only short-term improvements, attenuated improvements, or no improvement
in these measures [58, 27, 52].

Benzodiazepine-receptor agonists, categorized as hypnotic benzodiazepines (BZDs)1 or

non-benzodiazepine hypnotics,2 have been shown to be effective for the short-term
treatment of insomnia complaints such as sleep onset latency, number of nighttime
awakenings, total sleep time, and sleep quality, but there is no evidence of their
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effectiveness in the long-term [8, 59, 60, 61, 62]. Because there are risks associated with the
long-term use of these medications, particularly by older adults, use of these medications
beyond 35 days is not recommended [8]. Risks of long-term benzodiazepine use include
developing tolerance or dependence; rebound insomnia; residual daytime sedation; cognitive
impairment; and motor incoordination [8]. Additionally, both short-term and long-term use
of nonbenzodiazepines has been associated with increased risk of falls in institutionalized
older adults [63]. Due to the risks associated with pharmacotherapies and the equivalent or
superior effects seen with behavioral and CBTs in the long run, use of these medications
should generally be avoided in older people. The 2012 Beers Criteria from the American
Geriatrics Society recommended against use of all benzodiazepine medications for insomnia
among older adults, and recommended that non-benzodiazepine hypnotics be used for no

1estazolam, flurazepam, quazepam, temazepam, and triazolam

2zaleplon, zolpidem, and eszopiclone

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more than 90 days in this population [64]. Off-label use of pharmaceutics, such as
antidepressants, atypical antipsychotics, and anxiolytic benzodiazepine receptor agonists,
has also been widely used for treatment of insomnia. However, little research has been done
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on these drugs in insomnia patients, and due to concern over efficacy and proper dosage,
off-label pharmaceutics use is generally not recommended [65].

Randomized controlled trials have found that CBT interventions not only produce long-term
improvements on both subjective and objective measures of sleep, but also are more cost-
effective than pharmacotherapy [66, 67]. A trial comparing CBT to hypnotics in older adults
found that while the initial cost of CBT intervention was greater, over time it was
significantly more cost effective, including both costs of clinical implementation (e.g.,
training, supervision, and clerical support) and in increasing total quality-adjusted life years
[67]. Importantly, evidence suggests that CBT can reduce hypnotic use, which is especially
important in for older adults who are often long-term users of hypnotics, despite research
suggesting that long-term use can lead to maintenance of insomnia [67]. These findings
suggest that CBT is superior to pharmacotherapy in the long-term when considering both
clinical and patient-centered outcomes and cost, and should be considered as a first-line
therapy for chronic insomnia in older people.

Other treatments have been used to treat insomnia with varying degrees of effectiveness.
Melatonin supplements and synthetic melatonin agonists have both been shown to improve
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sleep in older adults with insomnia [68, 65]. Melatonin supplements are taken one to two
hours before bedtime to simulate the timing of the peak release of melatonin observed in
younger adults [69]. Large randomized controlled trials have shown that older adults
experience improvements in sleep latency, quality of sleep, morning alertness, and quality of
life [70, 71]. Synthetic melatonin agonists have a faster onset time (0.75 hours) than
melatonin supplements, and they produce many of the same results [65]. Randomized
controlled trials have shown that older adults using melatonin agonists have improved sleep
latency and sleep efficacy, and increased total sleep time, and do not show the same adverse
effects commonly seen in hypnotic treatment [72, 73]. Despite these positive findings, there
is still no overwhelming consensus that melatonin treatment is consistently effective for
treating insomnia in older adults, and more research needs to be done [68]. Lifestyle
interventions, which combine mild to moderate physical activity with social engagement,
have also been used to treat sleep disruption in older adults [8, 46]. Research has found that
these interventions can improve objectively measured quality of sleep, sleep-onset latency,
sleep duration, sleep efficiency, and self-reported measures of subjective sleep quality [8,
29, 30, 45, 46], potentially because both exercise and social stimulation act as circadian
synchronizers [28, 74]. Additionally, studies show that yoga, as opposed to more
conventional forms of physical activity, may be useful in reducing joint pain and sleep
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disturbances in OA patients [26, 75]. While these findings are promising, more research
needs to be done, particularly on the long-term benefits of these interventions.

5.1. Conclusion
To summarize, older adults commonly experience primary and comorbid insomnia.
Nonetheless, useful measures and effective interventions are available to treat insomnia in
this rapidly growing population. Behavioral and cognitive-behavioral therapies are safer and
more effective alternatives to hypnotic medications in the long-term for treatment of
insomnia in older people.

Acknowledgments
Funding: Ms. Wennberg is supported by the NIH/NIA Age-related Cognitive Disorders Training Program
fellowship (T32AG027668-05). Dr. Canham receives funding from the Drug Dependence Epidemiology Training

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 Wennberg et al. Page 7

Program supported by the National Institute on Drug Abuse (T32DA007292). Dr. Spira is supported by a Mentored
Research Scientist Development Award (1K01AG033195) from the National Institute on Aging. Dr. Smith was
supported by (R01AR05941, R01AR05487, and R01DA0329922). The content is solely the responsibility of the
authors and does not necessarily represent the official views of the National Institute on Aging, or the National
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