Medications for insomnia

Insomnia is highly prevalent among older adults and linked to a range of adverse outcomes, from memory and concentration difficulties to reduced daily functioning. While Cognitive Behavioural Therapy for Insomnia (CBT-I) is firmly established as the first-line treatment, limited access and practical barriers mean that many patients still end up receiving pharmacological therapy. This chapter considers the evidence for both approved and off-label medications in this setting. Placebo-controlled trials show that some hypnotic agents can deliver modest short-term improvements in sleep, yet convincing data on long-term benefit are missing. The prolonged use of benzodiazepine receptor agonists remains particularly concerning, given their association with cognitive decline, dependence, and falls. Off-label drugs such as trazodone or mirtazapine are widely prescribed, but evidence in older adults without psychiatric comorbidities is weak. In practice, the management of chronic insomnia in later life demands a careful balance: interventions should prioritize safety and effectiveness, with active patient involvement and regular reassessment at the core of treatment decisions.