Co-author: Louise Organista is an Advanced Clinical Pharmacist in the Frail Elderly Assessment team at the University Hospitals of Derby and Burton NHS Foundation Trust. She is also co-chair of the BGS Pharmacy Professionals Group. Louise posts on X via @Louise1401.
Co-author: Ian Wood is a GP in Buckinghamshire and UK Medical Director at Big Health, makers of Sleepio. He posts on Bluesky: @DrIanWood.bsky.social.
World Sleep Day on 15th March calls us to celebrate sleep but also to act on important issues in relation to it. In this article, we discuss why denying older people the right treatment for insomnia is putting their health at risk – and what needs to change.
Working in geriatrics, we see firsthand the significant toll that insomnia can take on older people.
Insomnia is the persistent difficulty in getting to sleep, maintaining sleep, or quality of sleep, resulting in impaired daytime functioning. It’s the plight of many and actually the most common mental health condition there is: between 6-10% of adults experience insomnia symptoms on at least three nights per week for three months or more.
Older adults are especially vulnerable: approximately 40% of people aged 65 and over experience insomnia regularly, with up to 75% suffering from some form of sleep disturbance.
Insomnia’s effects go far beyond fatigue. It’s a highly debilitating condition, impacting both mental and physical health and overall well-being - with persistent lack of sleep linked to increased risks of cardiovascular disease, diabetes, depression, anxiety and cognitive decline. It doesn’t just impact health either: older adults with insomnia spend significantly more time and money on medical visits and prescription medications compared to those without sleep disorders.
How should we treat it?
The National Institute for Health and Care Excellence (NICE) recommends cognitive behavioural therapy for insomnia (CBTi) as the first-line treatment.
CBTi tackles the root cause of the problem, addressing the cognitive and behavioural factors that cause insomnia. It’s backed by decades of robust evidence that demonstrates its safety, efficacy, and clinical effectiveness.
However, this proven treatment – which NICE recommends can be provided face-to-face or digitally - remains out of reach for the vast majority of people across England. That’s because face-to-face CBTi has long been largely unavailable due to a gross shortage of specialist trained therapists, and NHS England has still not made NICE-recommended digital CBTi available nationwide.
Sleeping tablets: a potential nightmare?
As a result of the lack of access to NICE-recommended digital CBTi, we clinicians are left with very few options for our patients. While sleep hygiene has sensible principles, it has not proven particularly effective for treating insomnia alone. Sleeping tablets (benzodiazepines and z-drugs) have been the de facto treatment for decades, yet their use is not recommended. NICE guidance clearly states that they should be avoided when possible due to significant adverse effects, including dependence, cognitive impairment, falls and fractures.
However, an analysis of NHS prescribing data suggests older people are one of the three groups most likely to be prescribed sleeping tablets. This is concerning given their increased susceptibility to the sedating and depressant effects of these medicines, as well as their heightened risk of serious injury and mortality following any fall. In addition, many in this age group contend with multiple comorbidities and medications, further underscoring the need to avoid sleeping tablets where possible.
