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Practice problem
In the primary care practice described in this paper, many older adults with chronic insomnia are prescribed zolpidem or a benzodiazepine, often for years. These drugs raise the risk of falls, confusion and car crashes in older adults, and the practice has no clear pathway to non-drug treatment. The practice and its patients are illustrative.
PICOT question
In adults aged 65 and older with chronic insomnia disorder (P), does cognitive behavioral therapy for insomnia (CBT-I) (I), compared with sedative-hypnotic medication (C), improve sleep outcomes and reduce medication-related harms (O) over 6 months (T)?
Evidence
American College of Physicians guideline (Qaseem et al., 2016). Based on a systematic review of randomized trials from 2004 to 2015, the ACP recommends that all adults receive CBT-I as the initial treatment for chronic insomnia disorder (strong recommendation, moderate-quality evidence). It recommends shared decision-making, including the benefits, harms and costs of short-term use of medications, before adding drug therapy for patients in whom CBT-I alone was unsuccessful (weak recommendation, low-quality evidence).
American Academy of Sleep Medicine guideline (Edinger et al., 2021). The AASM recommends multicomponent CBT-I for chronic insomnia in adults (strong). It suggests multicomponent brief therapies, and stimulus control, sleep restriction or relaxation therapy as single components (conditional), and suggests that clinicians not use sleep hygiene education as a single-component therapy.
AGS Beers Criteria (2023). The American Geriatrics Society advises avoiding benzodiazepines and the "Z-drug" hypnotics, such as zolpidem, in older adults because of risks including cognitive impairment, delirium, falls, fractures and motor vehicle crashes (2023 American Geriatrics Society Beers Criteria® Update Expert Panel, 2023).
Appraisal
| Source | Type | Strength |
|---|---|---|
| Qaseem et al. (2016) | Clinical practice guideline based on a systematic review | Strong recommendation for CBT-I first |
| Edinger et al. (2021) | Clinical practice guideline using GRADE | Strong recommendation for multicomponent CBT-I |
| AGS Beers Criteria (2023) | Consensus criteria based on a systematic review | Avoid benzodiazepines and Z-drugs in older adults |
The three sources agree. The guidelines are high-level evidence but address all adults, so applying them to older adults relies partly on subgroup data. Their main limitation in practice is access: trained CBT-I therapists are scarce in many areas.
Recommendation
- Offer CBT-I as first-line treatment to all older adults with chronic insomnia, delivered by a trained clinician, in groups, by telehealth or through a validated digital program when in-person therapy isn't available.
- Teach the core components: a consistent wake time, sleep restriction, stimulus control (using the bed only for sleep and getting up when unable to sleep) and challenging unhelpful beliefs about sleep.
- For patients already taking hypnotics, offer a slow, supervised taper alongside CBT-I.
- Don't rely on sleep hygiene handouts alone.
Evaluation
Over 6 months, the practice will track the Insomnia Severity Index, sleep diaries, the number of older adults with active hypnotic prescriptions, and reported falls.
References
2023 American Geriatrics Society Beers Criteria® Update Expert Panel. (2023). American Geriatrics Society 2023 updated AGS Beers Criteria® for potentially inappropriate medication use in older adults. Journal of the American Geriatrics Society, 71(7), 2052–2081. https://doi.org/10.1111/jgs.18372
Edinger, J. D., Arnedt, J. T., Bertisch, S. M., Carney, C. E., Harrington, J. J., Lichstein, K. L., Sateia, M. J., Troxel, W. M., Zhou, E. S., Kazmi, U., Heald, J. L., & Martin, J. L. (2021). Behavioral and psychological treatments for chronic insomnia disorder in adults: An American Academy of Sleep Medicine clinical practice guideline. Journal of Clinical Sleep Medicine, 17(2), 255–262. https://doi.org/10.5664/jcsm.8986
Qaseem, A., Kansagara, D., Forciea, M. A., Cooke, M., Denberg, T. D., & Clinical Guidelines Committee of the American College of Physicians. (2016). Management of chronic insomnia disorder in adults: A clinical practice guideline from the American College of Physicians. Annals of Internal Medicine, 165(2), 125–133. https://doi.org/10.7326/M15-2175
