What Causes Insomnia in Older Adults and How Should It Be Treated?

The short answer

Insomnia is the most common sleep disorder in adults over 60, affecting 30–48% of this population. The primary causes are age-related changes in circadian rhythm and sleep architecture, medical comorbidities (pain, nocturia, respiratory conditions), psychiatric conditions (depression, anxiety), and medications. CBT-I is the recommended first-line treatment and is more effective than sleep medications in the long term.

What the evidence actually shows

The NIA identifies insomnia as the most common sleep problem in adults aged 60 and older, noting that it can be caused by stress, changes to routine, or underlying medical conditions. A landmark RCT by Morin et al. (1999) in JAMA compared CBT-I to temazepam (a benzodiazepine) and their combination in older adults with insomnia. At 24-month follow-up, CBT-I produced superior outcomes to medication alone, with 90% of CBT-I patients maintaining improvement versus 15% of those who received medication only. The American College of Physicians (Qaseem et al., 2016) issued a clinical practice guideline recommending CBT-I as the first-line treatment for chronic insomnia disorder in adults.

"Cognitive behavioural therapy for insomnia produced superior long-term outcomes compared to pharmacotherapy, with 90% of patients maintaining improvement at 24 months."

— Morin et al., JAMA 1999

What the major health authorities say

The NIH National Institute on Aging recommends healthy sleep habits (consistent sleep/wake times, limiting caffeine and alcohol, keeping the bedroom cool and dark) as the first approach to managing insomnia, with CBT-I as the recommended treatment for chronic insomnia. The NIA explicitly cautions that sleep medications carry risks in older adults — including falls, cognitive impairment, and dependence — and should not be used long-term. Keeping a sleep diary for 2 weeks before a medical appointment is recommended to help identify patterns.

Practical implications

If you have chronic insomnia (difficulty sleeping at least 3 nights per week for more than 3 months), CBT-I is the most effective available treatment. It is now available digitally through apps such as Sleepio and through NHS-commissioned services in the UK. The core components are sleep restriction therapy (temporarily reducing time in bed to consolidate sleep), stimulus control (using the bed only for sleep and sex), and cognitive restructuring (addressing catastrophic thoughts about sleep). Avoid over-the-counter antihistamine sleep aids — they cause next-day sedation and cognitive impairment in older adults.

Where reasonable people still disagree

• Whether digital CBT-I programmes provide equivalent efficacy to therapist-delivered CBT-I for all severity levels of insomnia.
• The appropriate role of low-dose melatonin for circadian-related insomnia in older adults, where evidence is more mixed.
• Whether sleep restriction therapy is appropriate for older adults with cardiovascular disease, given transient increases in daytime sleepiness.