Insomnia in older adults: what changes with age, why CBT comes first and what melatonin and supplements can do

Sleep over 60: what’s a normal change

Many people in their sixties notice the same thing: sleepy by ten, awake at five, and up once or twice in between. According to the NIA, that’s how sleep often changes with age. Older adults tend to go to bed and wake earlier. Sleep gets shorter and lighter, and waking in the night becomes more common.

What doesn’t change much is how much sleep you need: about 7–9 hours, as for younger adults. So the question isn’t “Am I sleeping like I did at 30?” It’s “Do I feel all right during the day?”

Things that make sleep worse later in life are often fixable:

• pain, a full bladder at night, heartburn;
• medicines and alcohol, even a small evening drink;
• naps late in the afternoon;
• low mood, worry, loneliness;
• sleep disorders that become more common with age: sleep apnoea and restless legs.

Pick what sounds most like you:

Insomnia in older adults: when it’s more than ageing

The NIA calls insomnia the most common sleep problem in adults aged 60 and over: trouble falling or staying asleep on at least three nights a week. The NHS calls it short-term if it lasts less than 3 months and long-term if it lasts 3 months or more. Typical signs are trouble falling asleep, lying awake, waking too early, and feeling tired, irritable or unable to concentrate the next day.

Start with the basics the NHS recommends:

• get up at the same time every day, even after a bad night;
• go to bed only when you’re sleepy, and relax for an hour beforehand;
• keep the bedroom dark, quiet and comfortable;
• no tea, coffee, alcohol or cigarettes for 6 hours before bed;
• be active in the day, but not in the 4 hours before bed;
• avoid daytime naps.

If that doesn’t help within a few weeks, see your GP. Before you go, keep a sleep diary for about two weeks, as the NIA suggests. Note when you go to bed, when you wake in the night and in the morning, plus caffeine, alcohol and exercise.

CBT for insomnia comes first

For long-term insomnia, NICE treats cognitive behavioural therapy for insomnia (CBTi) as the standard first-line treatment. It works on the habits and thoughts that keep you awake. You can do it with a therapist or through a digital programme, and NICE recommends one such online programme for use in the NHS.

In NICE’s appraisal, clinical experts said that 70–80% of people respond to CBTi, and about half of those stay well in the long term. Access varies across the country, so ask your GP what’s available locally. Don’t let a waiting list push you into pills by default.

Sleeping pills and falls: why they’re used sparingly

GPs now rarely prescribe sleeping pills for insomnia, says the NHS, because of serious side effects and the risk of dependence. When they are used, it’s for a few days, or weeks at most. Zopiclone, for example, isn’t usually prescribed for more than 4 weeks.

After 65 the case against them is stronger. The Beers Criteria from the American Geriatrics Society are a widely used list of medicines to avoid in older adults. According to them, benzodiazepines and “Z-drugs” (zopiclone, zolpidem) cause delirium, falls, fractures and road accidents in older people, while improving sleep only slightly.

Night-time trips to the toilet make this worse. If you take anything sedating, make the route safe:

• a night light in the hallway or bathroom;
• no loose rugs or cables on the way;
• a lamp you can reach from bed;
• a phone with emergency numbers by the bed;
• fewer drinks late in the day, so you get up less often.

Never stop a sleeping pill you’ve taken for a long time all at once. Ask your GP how to reduce it gradually.

Avoid antihistamine sleep aids in older age

Many over-the-counter sleep aids in UK pharmacies contain a sedating antihistamine, such as diphenhydramine or promethazine. The Beers Criteria advise older adults to avoid these medicines. They’re highly anticholinergic (they block a nerve messenger called acetylcholine), and the body clears them more slowly with age. Tolerance builds when they’re used for sleep. They can cause confusion, dry mouth and constipation. Long-term exposure to anticholinergic medicines is linked to falls, delirium and dementia.

Pharmacy sleep aids shouldn’t be taken for more than 1–2 weeks, the NHS adds, and they can make you drowsy, which matters if you drive. If you already take other medicines, list them with our medicines list for your GP before buying anything for sleep.

Melatonin for the elderly: what’s licensed in the UK

In the UK melatonin is a prescription-only medicine. The NHS says it’s mainly used for short-term sleep problems in people aged 55 and over. The licensed product is a 2 mg prolonged-release tablet for primary insomnia from the age of 55. You take it 1–2 hours before bedtime, after food, for up to 13 weeks. Swallow it whole: crushing it spoils the slow release.

How much it helps, according to the product’s trials:

In a 3-week trial, people taking it reported falling asleep 24.3 minutes faster, against 12.9 minutes on placebo. Sleep quality and morning alertness both clearly improved in 26% of them, against 15% on placebo. In a sleep-lab study, it shortened the time to fall asleep by 9 minutes compared with placebo. That’s real, but modest. Points to know before you ask your GP:

• older people clear melatonin more slowly, so blood levels run higher than in younger adults;
• melatonin can add to the effect of zopiclone, zolpidem and benzodiazepines;
• the antidepressant fluvoxamine raises melatonin levels sharply, so the product information advises caution;
• don’t combine it with herbal sleep remedies, says the NHS, as you may get very drowsy;
• tell your GP if you have liver or kidney problems or an autoimmune condition.

Supplements sold on iHerb aren’t the same as the licensed tablet: doses and release vary, and they may not ship to the UK. Elsewhere in Europe the rules differ by country: some allow low-dose melatonin in food supplements, others treat it as a medicine. Our melatonin and sleep supplements guide covers doses and quality.

Magnesium and L-theanine: modest evidence

Magnesium is cheap and gentle in the glycinate form, but don’t expect a sleeping pill. With kidney disease, magnesium can build up; see supplements and kidney disease. L-theanine, an amino acid from tea, may take the edge off a busy mind. Our L-theanine guide has the trial details. Glycine, another mild option, has only small Japanese studies behind it; see glycine for sleep.

When to see your GP

• Trouble sleeping for months, or it’s affecting how you cope with daily life.
• Loud snoring with pauses in breathing: possible sleep apnoea. Untreated, it can lead to heart problems, and it has its own treatment, such as a CPAP machine.
• An urge to move your legs in the evening: possible restless legs. Treatment with iron (if a blood test shows you need it) or medicines usually helps, so see your GP before buying iron.
• Low mood, worry or pain keeping you awake.
• You’ve been on sleeping pills for more than a few weeks.

How to choose a sleep supplement on iHerb after 60

1. Fix the basics and try CBTi first; a supplement is an extra, not the treatment.
2. Choose one single-ingredient product, not a “sleep complex” with several herbs.
3. Avoid products with diphenhydramine or doxylamine: they’re medicines, not supplements.
4. Check your medicines for sedatives, and show the label to your pharmacist.
5. Give it 2–4 weeks, keep the sleep diary going and stop if nothing changes.

For more on sleep and stress, see our sleep and stress section, and for everyday supplements after 50, read vitamins for over 50s.