Sleep problems in the elderly, and the approach to insomnia in a 65-year-old recently retired professional

Burden and normal ageing changes. More than half of people over 65 report a sleep-related problem. Normal ageing produces a shorter, more superficial and more fragmented total sleep time, with increased sleep latency, reduced slow-wave (N3) and REM sleep, and more awakenings; 50–80% of older adults nap in the daytime, which itself indicates that night sleep is unrefreshing. Insomnia is the commonest sleep disorder in older people, with a prevalence of 40–50% over the age of 65.

The spectrum of sleep disorders in old age.

Assessment. For most of these disorders a detailed history is sufficient. Characterise the complaint precisely — delayed sleep onset, frequent awakenings or early-morning waking — and take a collateral history from the bed partner (snoring, apnoeas, kicking, dream enactment). Use a 2-week sleep diary, with actigraphy where available. Screen for depression, cognition, alcohol and the full drug chart, and examine for causes. Reserve polysomnography for suspected OSA, periodic limb movement disorder or REM sleep behaviour disorder — it is not needed for uncomplicated insomnia. Address unrealistic sleep expectations (such as the belief that 8 unbroken hours are essential).

The retired 65-year-old — the specific approach. Retirement from a busy professional career removes the external time cues (zeitgebers) that anchored the circadian rhythm — fixed waking time, morning light exposure, daytime activity and social contact. The typical sequence is later and irregular rising, long daytime naps, reduced physical activity and light exposure, an earlier bedtime, excessive time in bed, loss of role and purpose with low mood, and increased evening alcohol. Management is therefore behavioural, not pharmacological: (i) fixed wake-up time seven days a week; (ii) bright morning light exposure and outdoor activity; (iii) regular daytime exercise, avoided within 3 hours of bedtime; (iv) abolish or limit naps to under 30 minutes before 3 pm; (v) restrict time in bed to actual sleep time (sleep restriction) and use the bed only for sleep and sex (stimulus control); (vi) build a new structure of daily purpose and social engagement; (vii) limit caffeine after midday and evening alcohol and fluids; (viii) screen for and treat depression.

Treatment principles and drug safety. Sleep hygiene measures and cognitive behavioural therapy for insomnia (CBT-I) are first-line and should be tried BEFORE any pharmacological treatment; brief cognitive therapy is effective and avoids the long-term side effects of drugs. If a drug is unavoidable, use it for acute insomnia only, at the lowest dose and for the shortest time, with a planned stop date. Benzodiazepines and Z-drugs (zolpidem, zopiclone) should be avoided in older adults — they are on the AGS Beers list and cause falls, hip fracture, cognitive impairment, delirium, daytime sedation, road accidents, tolerance and dependence. Also avoid sedating antihistamines and tricyclics because of anticholinergic burden. Safer options where indicated: low-dose melatonin or prolonged-release melatonin, very low-dose doxepin, and treatment of the underlying cause. Always deprescribe long-term hypnotics gradually with behavioural support.

Dual orexin receptor antagonists (DORAs) have changed the pharmacological hierarchy. Lemborexant, daridorexant and suvorexant promote sleep by blocking wake-promoting orexin signalling rather than by non-selective GABA-A sedation, and randomised data in adults aged 65 and over show improved sleep onset and maintenance with improved daytime functioning and, importantly, no worsening of postural stability or next-morning falls risk compared with Z-drugs. Current guidance (AASM and the AGS Beers Criteria 2023, which continue to advise against benzodiazepines and Z-drugs in older adults) positions DORAs as the preferred pharmacological option when CBT-I has failed — although CBT-I remains first-line and drug treatment should still be short-term.