DIET & NUTRITION 
PATIENT EDUCATION 
OBESITY/WEIGHT MANAGEMENT 
EXERCISE/TRAINING 
LEGAL MATTERS 
GUIDELINES/RECOMMENDATIONS 
Up to 50% of older adults struggle with sleep despite unchanged sleep needs, yet most insomnia medications carry serious risks including falls, cognitive impairment, and fractures in this population. Cognitive behavioral therapy remains gold standard but clinicians and patients often choose “quick fix” medications instead.
🔍 CLINICAL CONSIDERATIONS
- Benzodiazepines, Z-drugs, and antihistamines all appear on Beers Criteria as high-risk medications that should be avoided in older adults
- Low-dose doxepin (3-6 mg) is only FDA-approved antidepressant for insomnia, showing efficacy without anticholinergic effects at studied doses
- Dual orexin receptor antagonists demonstrate strong safety profiles with numbers needed to harm ranging from 78 to over 1,000 patients
- Sleep restriction therapy alone produced medium to large sustained effects at 6 months when nurse-delivered in primary care settings
🎯 PRACTICE APPLICATIONS
- Reserve benzodiazepines and Z-drugs for acute use only given fall and confusion risks
- Consider low-dose doxepin, ramelteon, or dual orexin antagonists as safer long-term alternatives
- Implement sleep restriction by limiting bed time to actual sleep hours, gradually increasing
- Refer patients to CBTI apps or providers before defaulting to pharmacologic treatment
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